Eyelid disorders

Allergic reaction, local

Itching, no pain

Pale, puffy eyelid or eyelids, conjunctiva, or both

Sometimes history of recurrence, exposure to allergen, or both

Unilateral or bilateral

History and physical examination

Blepharitis

Lash involvement and crusting usually visible grossly or under magnification (eg, with slit lamp)

Itching, burning, redness, ulceration, or a combination

Sometimes concomitant seborrheic dermatitis

Unilateral or bilateral

History and physical examination

Chalazion

Focal redness and pain involving only one eyelid

Eventual development of localized, nonpainful swelling away from eyelid margin

History and physical examination

Conjunctivitis, infectious

Conjunctival injection, discharge

Sometimes preauricular node, chemosis, or both

Unilateral or bilateral

herpes simplex keratoconjunctivitis

Herpes simplex blepharitis (primary)

Clusters of vesicles on an erythematous base, ulceration, severe pain

Unilateral

History and physical examination

Herpes zoster (shingles)

Clusters of vesicles on an erythematous base, ulceration, severe pain

Unilateral, V₁nerve root distribution

History and physical examination, including ophthalmic examination if eye involvement is suspected

Hordeolum

Focal redness and pain involving only one eyelid

Eventual development of swelling localized to eyelid margin, sometimes with pustule

History and physical examination

Insect bite

Itching, redness, sometimes a papule

History and physical examination

Disorders in and around the orbit

Cavernous sinus thrombosis (rare)

Headache, proptosis, ophthalmoplegia, ptosis, decreased visual acuity, fever

Usually unilateral at first, then bilateral

Manifestations of sinusitis or other facial infection

Immediate CT or MRI of brain and orbits

Orbital cellulitis

Proptosis, redness, fever, pain

Impaired or painful extraocular movements

Sometimes decreased visual acuity

Usually unilateral

Sometimes preceded by manifestations of the source infection (typically sinusitis)

CT or MRI of orbits

Preseptal cellulitis (periorbital cellulitis)

Swelling (but not proptosis), redness, sometimes pain, fever

Usually unilateral

Vision and ocular motility normal

Sometimes preceded by manifestations of the source infection (typically local skin infection)

CT or MRI of orbits if necessary to exclude orbital cellulitis

Systemic disorders*

Allergic reaction, systemic (eg, angioedema, rhinitis)

Itching

Sometimes extraocular allergic manifestations (eg, urticaria, wheezing, rhinorrhea)

Sometimes history of recurrence, exposure to allergen, atopy, or a combination

Usually bilateral

History and physical examination

Generalized edema

Bilateral asymptomatic eyelid and sometimes facial edema; usually also edema of dependent body parts (eg, feet, presacral region)

Usually manifestations of underlying disorder (eg, chronic renal disease, heart failure, liver failure, preeclampsia)

Sometimes use of an angiotensin-converting enzyme (ACE) inhibitor

Testing for cardiac, hepatic, or renal disorders as clinically directed

Hyperthyroidism (with Graves ophthalmopathy)

Stare, eyelid lag, proptosis, impaired extraocular movements

Not painful unless cornea is irritated from drying

Tachycardia, anxiety, weight loss

Thyroid function tests (TSH, T4)

Hypothyroidism

Painless, bilateral diffuse facial puffiness

Dry, scaly skin; coarse hair

Cold intolerance

Thyroid function tests (TSH, T4)