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Eyelid Swelling

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Title: Eyelid Swelling

Author (s): Andy Renschler MS4

Author Email: andy.renschler@hsc.utah.edu

Photographer: Paul Crown

Date:8/19/25

Keywords/Main Subjects: eyelids, blepharitis, dermatitis, angioedema, dacryocystitis

Diagnosis: blepharitis, dermatitis, angioedema, dacryocystitis

Description of Case:

Eyelid swelling results from increased vascular permeability and fluid extravasation into eyelid tissues, often triggered by infection or inflammatory reactions. Important historical components when assessing eyelid swelling includes duration and progression of symptoms, pain, prurititis, systemic symptoms, visual changes, recent trauma, and history of allergies. A differential for common etiologies of eyelid swelling is discussed below. Other notable causes of eyelid swelling include chalazions, hordeolums, pre-septal cellulitis, and orbital cellulitis. Please refer to following links for more information regarding these topics: Eye lid masses and Cellulitis.

Blepharitis:

Image 1: Demodex folliculorum infestation characterized by cylindrical dandruff around eyelash follicles.

Image 1: Demodex folliculorum infestation characterized by cylindrical dandruff around eyelash follicles.

Blepharitis is ocular irritation caused by chronic inflammation of the eyelid margin; it is categorized into anterior and posterior blepharitis. Posterior blepharitis is characterized by inflammation of the inner portion of the eyelid at the level of the meibomian glands while anterior blepharitis is characterized by inflammation at the base of the eyelids adjacent the eyelash follicles1. Hyperkeratinization of the meibomian glands is an early finding of posterior blepharitis with potential etiologies including but not limited to rosacea and seborrheic dermatitis2,3. When assessing anterior blepharitis, infectious etiologies should be considered in addition to chronic inflammatory conditions. Demodex folliculorum mites have been reported as a common agent although bacterial, fungal, and viral etiology can also occur4. Demodex mites cause direct damage to the lash follicles and meibomian glands providing opportunity for secondary pathogens. Scaling, crusting, and erythema of the eyelids particularly in the morning are common complaints of any kind of blepharitis, but collarettes (cylindrical dandruff) at the base of the eyelashes are pathognomonic for Demodex folliculorum blepharitis (see image 1)4. Demodex folliculorum mites are identified in roughly 30% of patients with chronic anterior blepharitis, although similar prevalence rates have been documented in asymptomatic individuals5,6. Nevertheless, its role as an etiologic agent is supported by clinical improvement after therapy6. Staph aureus and Staph epidermidis also commonly cause blepharitis independent of prior Demodex infestation; cylindrical dandruff will not be seen in these cases. Chronic dry eye is frequently coexistent with staph blepharitis and is reported to be present in 50% of patients with this kind of blepharitis with theories suggesting a decrease in local lysozyme and immunoglobulin secondary to tear deficiency may be a predisposition for staph infection7. Additionally, studies have shown females in their 40s are the most commonly affected population by staph blepharitis7. Initial treatment for Demodex blepharitis includes lotilaner drops (an antiparasitic agent) in addition to warm compresses with diluted baby soap; persistent or more severe bacterial cases can be managed with topical antibiotics such as bacitracin or erythromycin ointment8.

Atopic/contact dermatitis:

Image 2: Dermatitis characterized by scaling of forehead, nose, and right eyelid.

Image 2: Dermatitis characterized by scaling of forehead, nose, and right eyelid.

The eyelids are particularly vulnerable to developing dermatitis due to several unique anatomical and physiological features. The eyelid skin is remarkably thin, with a stratum corneum that is only a few cell layers thick resulting in increased permeability to allergens and irritants compared to other skin sites. The skin of the eyelids has a rich vascular and lymphatic supply which can amplify an inflammatory response. Additionally, the eyelids are in a relatively vulnerable location on the body with constant exposure to airborne irritants/allergens. Frequent application of cosmetic products or simply frequent touching of the lids also contribute to the development of dermatitis9. It presents as well-demarcated erythema, edema and pruritus of the upper and/or lower lids, often with scaling and dryness; chronic exposure may result in lichenification, fissuring, or persistent hyperpigmentation. Erythema is not always present; as image 2 depicts how dermatitis can present on the forehead, nose, and eyelid10. Discussing recent exposures may assist in diagnoses when clinical features are inconclusive, but definitive diagnosis is with patch testing10. The most effective treatment is avoidance of the allergen if it can be identified, but topical corticosteroids can also be used for short-term control of acute inflammation11.

 

Angioedema:

Angioedema is rapid, localized swelling of the deep dermis and subcutaneous tissue of the eyelid resulting in nonpitting edema. Allergic reactions are a result in mast cell-mediated release of histamine resulting in swelling while high concentrations of bradykinin (seen in hereditary angioedema or ACE inhibitor-induced angioedema) can also have a similar presentation12. Neither form of angioedema is associated with erythema or warmth making this a useful way of differentiating from other types of eyelid swelling. Treatment of angioedema caused by allergic reactions is managed with IM epinephrine (if concern for anaphylaxis or airway involvement) and antihistamines; bradykinin-induced angioedema does not respond to antihistamine therapy and may require C1-inhibitor concentrate such as icatibant or ecallantide with definitive management of stopping the offending drug13.

Dacryocystitis:

Image 3: Dacryocystitis characterized by erythematous, fluctuant mass inferior to the medial canthal tendon.

Image 3: Dacryocystitis characterized by erythematous, fluctuant mass inferior to the medial canthal tendon.

Dacryocystitis is caused by infection (most commonly staph and strep) of the lacrimal sac secondary to nasolacrimal duct obstruction characterized by acute, localized pain, erythema, and discharge from the punctum. A fluctuant mass may also be present below the medial canthal tendon (see image 3). Risk factors include increasing age and female sex, especially in the presence of primary acquired nasolacrimal duct obstruction (PANDO), the idiopathic obstruction of the nasal lacrimal duct in adulthood14. Congenital malformation of the nasolacrimal duct can also increase risk of developing dacryocystitis which would be expected to present during childhood. Treatment includes systemic antibiotics with amoxicillin-clavulanate or fluoroquinolones to target gram-positive and gram-negative organisms in conjunction with warm compresses to relieve the obstruction; needle aspiration or incision & drainage may be required if an abscess has formed15. Definitive management for chronic duct obstruction involves dacryocystorhinostomy to prevent future obstructions16.

Images or video:

Summary of the Case: The etiology of eyelid swelling includes a broad differential. The following text provides a reasonable approach to assessing eyelid swelling with notable characteristics and a brief recommendation for treatment.

Format: text

References:

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  2. McCulley JP, Dougherty JM, Deneau DG. Classification of Chronic Blepharitis. Ophthalmology. 1982;89(10):1173-1180. doi:10.1016/S0161-6420(82)34669-2
  3. Driver PJ, Lemp MA. Meibomian gland dysfunction. Surv Ophthalmol. 1996;40(5):343-367. doi:10.1016/S0039-6257(96)80064-6
  4. Current state and future perspectives in the diagnosis of eyelid margin disease: clinical review. Accessed July 8, 2025. https://oce-ovid-com.ezproxy.lib.utah.edu/article/02158034-202408000-00015/HTML
  5. Roth AM. Demodex folliculorum in hair follicles of eyelid skin. Ann Ophthalmol. 1979;11(1):37-40.
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  8. Eyelid margin disease (blepharitis and meibomian gland dysfunction): clinical review of evidence-based and emerging treatments. Accessed July 8, 2025. https://oce-ovid-com.ezproxy.lib.utah.edu/article/02158034-202408000-00016/HTML
  9. Wolf R, Orion E, Tüzün Y. Periorbital (eyelid) dermatides. Clin Dermatol. 2014;32(1):131-140. doi:10.1016/j.clindermatol.2013.05.035
  10. Hine AM, Waldman RA, Grzybowski A, Grant-Kels JM. Allergic disorders of the eyelid. Clin Dermatol. 2023;41(4):476-480. doi:10.1016/j.clindermatol.2023.08.002
  11. Fonacier L, Bernstein DI, Pacheco K, et al. Contact Dermatitis: A Practice Parameter–Update 2015. J Allergy Clin Immunol Pract. 2015;3(3):S1-S39. doi:10.1016/j.jaip.2015.02.009
  12. Maurer M, Magerl M. Differences and Similarities in the Mechanisms and Clinical Expression of Bradykinin-Mediated vs. Mast Cell–Mediated Angioedema. Clin Rev Allergy Immunol. 2021;61(1):40-49. doi:10.1007/s12016-021-08841-w
  13. Depetri F, Tedeschi A, Cugno M. Angioedema and emergency medicine: From pathophysiology to diagnosis and treatment. Eur J Intern Med. 2019;59:8-13. doi:10.1016/j.ejim.2018.09.004
  14. Demeuleneere A, Kusmierczyk J, Mombaerts I. Risk factors for the development of acute dacryocystitis in adults. Br J Ophthalmol. Published online June 18, 2025. doi:10.1136/bjo-2024-326753
  15. Chi YC, Lin CC, Chiu TY. Microbiology and Antimicrobial Susceptibility in Adult Dacryocystitis. Clin Ophthalmol Auckl NZ. 2024;18:575-582. doi:10.2147/OPTH.S452707
  16. Yu B, Tu Y, Zhou G, Hong H, Wu W. Immediate Endoscopic Dacryocystorhinostomy in Patients With New Onset Acute Dacryocystitis. The Laryngoscope. 2022;132(2):278-283. doi:10.1002/lary.29693

 

Faculty Approval by: Dr. Griffin Jardine

Copyright: Copyright Andy Renschler, ©2025. For further information regarding the rights to this collection, please visit: http://morancore.utah.edu/terms-of-use/