Diagnostic puzzler: Acute eyelid edema
The patient’s eyelid was not inflamed or painful, but it was swollen enough to impair his vision. What’s your diagnosis?
This disorder can result from optic neuropathy, exudative retinal detachment, or uveitis. It is a diagnosis of exclusion and is often arrived at by seeing the patient respond to systemic corticosteroids. The specific drug and dose will vary based on disease severity.
Graves’ ophthalmopathy. This bilateral, asymmetric immunological disorder affects the conjunctiva, eyelids,8 extraocular muscles, lacrimal gland, and optic nerve. Although it is typically diagnosed clinically, thyroid hormone abnormalities (increased T4 and a drop in thyroid-stimulating hormone) help support the diagnosis. In the acute phase, it has to be treated with systemic steroids; if the condition becomes chronic, the complications may require surgery. Treatment of the underlying hyperthyroidism may, in some cases, worsen the ophthalmopathy.
One more consideration. Finally, consider a local allergic reaction in the eyelids,9 which can also cause painless palpebral edema. Expect to see erythematous edema and intense itching a few hours after exposure to the allergen. A cosmetic product is often the culprit. As you might expect, initial treatment calls for withdrawal of the offending product. Instruct the patient to apply a topical steroid ointment on the eyelid if the edema is intense.
Good news for our patient
Diagnosing noninflammatory eyelid edema requires keen observational skills and a knowledge of several alternative diagnoses. Fortunately for our patient, this benign condition did not require any local or systemic treatment. The edema resolved on its own in 6 days.
CORRESPONDENCE
Omar Rayward, MD, Calle Profesor Martín Lagos, Madrid, Spain 28040; orayward@yahoo.com
