What is the management for a female patient with persistent periorbital swelling 4 weeks after a dilation and curettage (D&C) procedure?

Management of Persistent Periorbital Swelling 4 Weeks Post-D&C

This patient requires urgent ophthalmologic evaluation to rule out vision-threatening orbital involvement, followed by systematic investigation for medication-related angioedema, inflammatory conditions, and infectious etiologies.

Immediate Assessment Required

The 4-week duration of periorbital swelling following a D&C procedure is abnormal and demands comprehensive evaluation. Visual acuity testing is essential as any decrease suggests orbital involvement requiring urgent intervention 1. The following clinical features must be assessed immediately:

• Proptosis assessment - indicates intraorbital pathology and is strongly associated with abscess formation 1
• Extraocular movement testing - pain with movement or ophthalmoplegia signals orbital involvement 1
• Pupillary examination - changes in size or reactivity suggest optic nerve compromise 1
• Intraocular pressure measurement - elevated pressure may indicate orbital compartment syndrome 1
• Conjunctival assessment - injection or chemosis suggests orbital involvement 1

Immediate ophthalmology consultation is mandatory for any patient with vision-threatening features 1.

Diagnostic Workup

Medication Review

Medication-related angioedema must be excluded first, as this is a common and reversible cause. Periorbital angioedema can occur even after long-term medication use 2. Review all medications started before or after the D&C procedure, particularly:

• Aspirin and salicylate derivatives (can cause periorbital angioedema even after years of use) 2
• ACE inhibitors
• NSAIDs
• Antibiotics prescribed post-procedure

Imaging Considerations

Emergent CT orbits with contrast is necessary if high-risk features are present to identify abscess, foreign body, or structural abnormality 1.

Management Algorithm

If Corneal Involvement is Present

First-line medical management consists of topical sodium chloride 5% solution or ointment to reduce corneal edema through hyperosmotic effect 3, 4.

Additional corneal management includes:

• Control inflammation with topical corticosteroids after excluding infection 3, 4
• Avoid topical carbonic anhydrase inhibitors as first-line therapy when endothelial dysfunction exists, as they interfere with the endothelial pump 3, 4
• Avoid prostaglandin analogues if inflammation is present due to their pro-inflammatory properties 3, 4
• Adjunctive hair dryer use can provide temporary symptomatic benefit 3

If Medication-Related Angioedema is Suspected

Discontinue the offending medication immediately - this typically results in quick recovery from swelling 2. Substitution with alternative agents (e.g., replacing aspirin with anticoagulants) has demonstrated rapid resolution 2.

If Inflammatory Etiology is Suspected

Persistent periorbital edema may represent cutaneous lupus erythematosus or other autoimmune conditions, especially when accompanied by conjunctival injection 5. This requires:

• Rheumatologic workup including ANA, anti-dsDNA, complement levels
• Skin biopsy if cutaneous lesions develop
• Systemic corticosteroid therapy may be necessary

If Infectious Etiology Cannot be Excluded

While less likely 4 weeks post-procedure, preseptal or orbital cellulitis must be considered if there is:

• Erythema and warmth of eyelids
• Fever or systemic symptoms
• Progressive worsening

This requires broad-spectrum antibiotics and possible hospitalization 1.

Common Pitfalls to Avoid

• Do not dismiss prolonged periorbital swelling as "normal post-procedure edema" - 4 weeks is excessive and warrants investigation 6
• Do not overlook medication-related causes - angioedema can develop even after years of stable medication use 2
• Do not delay ophthalmology referral if any vision-threatening signs are present 1
• Do not use cool compresses without screening for cold urticaria - this can paradoxically worsen swelling in susceptible patients 7

Follow-up Strategy

• Monitor visual acuity, intraocular pressure, and treatment response regularly 4
• If bandage contact lenses are used for corneal protection, provide prophylactic broad-spectrum topical antibiotics and educate about infectious keratitis risk 3, 4
• Reassess if swelling persists beyond 2 weeks of appropriate management - consider biopsy to exclude rare tumors or infiltrative processes 6