What causes eye puffiness?

Eye Puffiness: Causes and Clinical Approach

Eye puffiness (periorbital edema) results from multiple mechanisms including eyelid laxity with mechanical trauma, allergic inflammation, fluid retention from systemic disease, infectious/inflammatory processes, or localized anatomical abnormalities.

Primary Eyelid-Related Causes

Floppy Eyelid Syndrome

• Characterized by upper eyelid edema, easily everted upper lid, and horizontal lid laxity that causes chronic mechanical irritation during sleep 1, 2
• Strongly associated with obesity, sleep apnea, and middle-aged males 3, 4
• The loose eyelid spontaneously everts during sleep, causing chronic papillary conjunctivitis and persistent puffiness 3, 4
• Often misdiagnosed due to non-specific symptoms (redness, foreign body sensation, tearing) 3

Allergic Mechanisms

• Allergic conjunctivitis causes eyelid swelling through histamine-mediated vascular permeability and inflammation 5
• Contact allergy to cosmetics, ophthalmological preparations, or medications (including sympathomimetics like phenylephrine) can cause pure edematous eyelid swelling 6
• Giant papillary conjunctivitis from contact lens wear presents with upper eyelid swelling and requires discontinuation of lenses 1
• Eye rubbing from uncontrolled allergic disease worsens edema and can lead to complications 5

Infectious and Inflammatory Causes

Preseptal Cellulitis

• Common cause of upper eyelid swelling requiring high-dose amoxicillin-clavulanate with daily follow-up 1
• Hospitalization indicated if no improvement in 24-48 hours or progressive infection 1
• Must distinguish from orbital cellulitis (red flags: proptosis, painful eye movements, vision loss, fever) which requires immediate hospitalization, IV antibiotics, and urgent subspecialty consultation 1

Conjunctivitis-Associated Swelling

• Parinaud oculoglandular syndrome causes unilateral eyelid swelling with regional lymphadenopathy (cat scratch disease, tularemia) 5
• Chronic conjunctivitis from various etiologies (bacterial, viral, autoimmune) can cause persistent lid edema 5

Systemic Disease Manifestations

Nephrotic Syndrome

• In children with puffy eyelids and facial swelling, nephrotic syndrome must be excluded with urinalysis and serum albumin 7
• Often initially misattributed to allergy, delaying appropriate therapy 7

Thyroid Eye Disease

• Bilateral (but may be asymmetric) periorbital edema and conjunctival swelling 5
• Associated with Graves' disease, Hashimoto's thyroiditis, or normal thyroid function 5
• Can present with upper eyelid retraction, proptosis, and restrictive myopathy 5

Autoimmune and Vasculitic Disorders

• Sarcoidosis, granulomatosis with polyangiitis, and other vasculitides cause conjunctival inflammation with periorbital edema 5
• Stevens-Johnson syndrome/toxic epidermal necrolysis cause severe mucocutaneous involvement with eyelid swelling 5

Vascular and Microcirculatory Factors

• Microvasculature congestion and increased permeability contribute to infraorbital puffiness 8
• Hemoglobin degradation and melanin accumulation worsen the appearance of periorbital changes 8
• Chronic venous congestion from positional factors (sleeping position, eyelid malposition) perpetuates edema 3, 4

Critical Red Flags Requiring Urgent Evaluation

Immediate hospitalization is mandatory for: 1

• Proptosis
• Painful or restricted eye movements
• Decreased vision
• Fever or systemic toxicity
• Progressive infection despite treatment

Malignancy Considerations

• Sebaceous carcinoma can masquerade as chronic unilateral blepharoconjunctivitis with eyelid swelling 1
• Biopsy indications include: unifocal recurrent lesions, resistance to therapy, focal lash loss, and chronic unilateral presentation unresponsive to treatment 1
• Conjunctival neoplasms (melanoma, squamous cell carcinoma) may present with localized swelling and conjunctival injection 5

Common Pitfalls

• Attributing all eyelid swelling to allergy without excluding systemic disease (especially nephrotic syndrome in children) 7
• Missing floppy eyelid syndrome in obese patients with sleep apnea and chronic ocular irritation 3, 4
• Failing to recognize preseptal versus orbital cellulitis, delaying critical intervention 1
• Overlooking contact allergy to topical medications or cosmetics as a pure cause of edematous swelling 6
• Not evaluating for underlying thyroid disease in patients with bilateral periorbital edema 5