The patient is frightened by the facial distortion and itching that seem to appear
spontaneously or up to 24 hours after having been bitten by a bug or having contacted some
irritant. The patient may have been rubbing his eyes: in fact, an allergen or chemical irritant
on the hand may cause periorbital edema long before a reaction, if any, is evident on the skin
of the hand.
There may be minimal to marked generalized conjunctival swelling (chemosis), but
little injection. Tenderness and pain should be minimal or absent and there should be no
erythema of the skin, photophobia or fever. Visual acuity should be normal, there should be
no fluorescein uptake over the cornea and the anterior chamber should be clear.
What to do:
After completing a full eye exam, reassure the patient that this is not as serious as it looks.
Prescribe hydroxyzine (Atarax) 25-50mg q6h for mild to moderate swelling and a six-day
course of steroids (Aristopak 4mg) for more severe cases. Naphazoline (Vasocon, Naphcon)
ophthalmic drops will be soothing and reduce swelling when the conjunctiva is involved.
Instruct the patient to use cool compresses to reduce swelling and discomfort.
Inquire about the cause, including allergies and chemical irritants.
Warn the patient about the potential signs of infection.
What not to do:
Do not apply heat: swelling and pruritis will increase.
Do not confuse this with periorbital cellulitis, a serious infection manifested by pain, heat,
fever, deep erythema. Periorbital cellulitis requires hospitalization and aggressive antibiotic
The dramatic swelling that often brings a patient to an emergency department occurs because
of the loose connective tissue surrounding the orbit. Fluid quickly accumulates when a local
allergic-response causes increased capillary permeability, resulting in dramatic eyelid swelling.
The envenomation, allergen, or irritant responsible may actually be located some distance
away on the face (or hand) but the loose periorbital tissue is the first to swell.