What is the appropriate workup and initial management for periorbital swelling?

Workup for Periorbital Swelling

Begin with a focused history emphasizing temporal pattern (acute versus gradual onset), unilateral versus bilateral presentation, and associated symptoms including vision changes, pain, proptosis, or impaired eye movements, as these features guide the differential diagnosis and urgency of evaluation. 1

Critical History Elements

Temporal and Laterality Assessment

• Acute onset suggests infection (orbital cellulitis), allergic reaction, or trauma, while gradual onset points toward inflammatory conditions, thyroid eye disease, or neoplasm 1
• Unilateral presentation favors infection, trauma, or tumor; bilateral presentation suggests systemic causes including thyroid disease, allergy, or medication reaction 1
• Diurnal variation with morning worsening that improves throughout the day indicates endothelial dysfunction or fluid redistribution 1

Red Flag Symptoms Requiring Urgent Imaging

• Visual changes (blurred vision, diplopia, decreased acuity) indicate orbital involvement requiring urgent imaging 1
• Severe eye pain suggests acute angle-closure glaucoma, orbital cellulitis, or hordeolum 1
• Proptosis or globe displacement indicates orbital mass effect from abscess, hematoma, or tumor 1
• Impaired or painful extraocular movements suggest orbital cellulitis, thyroid eye disease, or subperiosteal abscess 1

Medication Review

• Topical medications: corticosteroids (elevated IOP), chlorhexidine (endothelial toxicity), amantadine (endothelial dysfunction) 1
• Systemic medications: sulfonamides including topiramate (ciliary body edema), anticholinergics, amiodarone, chemotherapeutic agents 1

Additional Historical Context

• Previous episodes of chalazia or hordeola suggest blepharitis or meibomian gland dysfunction 1
• Recent ocular surgery (cataract, YAG capsulotomy, intravitreal injections) increases complication risk 1
• Contact lens wear details including type, duration, and hygiene practices 1
• Trauma history: blunt/penetrating injury, chemical exposure, forceps delivery in neonates 1
• Family history: thyroid disease, glaucoma/angle-closure, corneal dystrophies, genetic syndromes 1
• Social factors: smoking (thyroid eye disease risk), UV exposure, animal exposure, recent travel 1

Physical Examination Components

External and Adnexal Examination

• Visual acuity measurement is mandatory for all patients 2, 1
• Inspect eyelid margins for inflammation, crusting, madarosis (lash loss), or masses 2
• Evaluate for cicatricial changes including subepithelial fibrosis, fornix foreshortening, or symblepharon formation 2
• Assess for asymmetry, which may indicate carcinoma requiring biopsy, especially with unifocal recurrent chalazia resistant to therapy 2

Slit-Lamp Biomicroscopy

• Examine conjunctiva for hyperemia, chemosis, follicles, or papillae 2
• Corneal evaluation with fluorescein staining to identify epithelial defects, infiltrates, ulcers, edema, or vascularization 2
• Anterior chamber assessment for inflammation or cells 2

Additional Examination Elements

• Intraocular pressure measurement 2
• Pupillary assessment for optic nerve dysfunction 2
• Extraocular motility testing, particularly if orbital involvement suspected 1
• Gonioscopy before dilation when neovascularization suspected or IOP elevated 2

Diagnostic Testing

Laboratory and Microbiologic Studies

• Cultures of eyelid margins indicated for recurrent anterior blepharitis with severe inflammation or treatment failure 2
• Microscopic evaluation of epilated eyelashes for Demodex mites (place on glass slide with fluorescein and coverslip) 2

Biopsy Indications

• Chronic blepharitis unresponsive to therapy, especially unilateral presentation 2
• Marked asymmetry, resistance to therapy, or unifocal recurrent chalazia 2
• Signs concerning for sebaceous carcinoma: loss of normal eyelid margin anatomy, focal lash loss (ciliary madarosis) 2
• Consult pathologist before biopsy for suspected sebaceous carcinoma to discuss frozen sections, conjunctival mapping for pagetoid spread, and need for fresh tissue with oil red-O staining 2

Immunofluorescence Studies

• Perform complete ocular surface examination for signs of conjunctival cicatricial changes in chronic blepharitis unresponsive to standard treatment 2
• If cicatrizing disease suspected, initiate workup for ocular mucous membrane pemphigoid including immunofluorescence studies of biopsy specimen 2

Imaging

• Urgent imaging (CT or MRI) required when visual changes, proptosis, severe pain with eye movement, or impaired extraocular movements present 1

Common Pitfalls

• Do not dismiss unilateral chronic blepharitis without considering malignancy, particularly sebaceous carcinoma 2
• Recognize that chronic blepharokeratoconjunctivitis in children is often unrecognized and should be suspected with recurrent conjunctivitis, keratitis, neovascularization, or chalazia 2
• Avoid missing cicatrizing conditions like ocular mucous membrane pemphigoid that can masquerade as chronic blepharitis 2
• Do not overlook systemic associations including thyroid disease, which requires specific workup when bilateral periorbital swelling with proptosis present 1