Severe Bilateral Periorbital Swelling: Causes, Diagnosis, and Management

Severe Bilateral Periorbital Swelling: Causes, Diagnosis, and Management

**Bilateral periorbital swelling** (swelling around both eyes) is a common but clinically significant sign that can indicate anything from a simple allergic reaction to a serious systemic or orbital disease. Recognizing the underlying cause early is crucial to prevent vision-threatening or life-threatening complications.

This article explains the **common causes, differential diagnosis, red flags, and management** of severe bilateral periorbital edema.

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## What Is Periorbital Edema?

Periorbital edema refers to **swelling of the tissues surrounding the eyes**, involving the upper and lower eyelids. It occurs due to fluid accumulation, inflammation, infection, or vascular permeability changes.

When swelling is **bilateral**, systemic or allergic causes are more likely than localized infection.

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## Common Causes of Bilateral Periorbital Swelling

### 1. Allergic Reaction / Angioedema (Most Likely)

**Key features:**

* Sudden onset

* Painless, non-pitting swelling 

* Often itchy

* Usually no redness or fever

**Causes include:**

* Food allergy

* Drug allergy (especially ACE inhibitors)

* Insect bites

* Idiopathic angioedema

👉 **Angioedema commonly affects eyelids and lips** and can be life-threatening if it involves the airway.

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### 2. Nephrotic Syndrome (Renal Cause)

**Classic cause of bilateral periorbital edema**

**Features:**

* Worse in the morning

* Pitting edema

* Associated with:

  * Facial puffiness

  * Pedal edema

  * Proteinuria

  * Hypoalbuminemia

Common in both children and adults with kidney disease.

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### 3. Thyroid Disorders

#### Graves’ Ophthalmopathy (Hyperthyroidism)

* Proptosis (bulging eyes)

* Lid retraction

* Dry, gritty eyes

#### Hypothyroidism (Myxedema)

* Non-pitting edema

* Thickened, coarse skin

* Puffy face and eyelids

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### 4. Cardiac or Hepatic Failure

Systemic fluid overload may cause:

* Bilateral periorbital edema

* Dependent edema (legs, sacrum)

* Shortness of breath or ascites

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### 5. Orbital or Preseptal Cellulitis (Less Likely if Bilateral)

Usually **unilateral**, but important to rule out.

**Red flags:**

* Fever

* Painful eye movements

* Redness

* Vision changes

* Proptosis

This is an **ophthalmic emergency**.

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## Important Red Flags 🚨

Seek **urgent medical attention** if any of the following are present:

* Fever

* Severe eye pain

* Vision loss or diplopia

* Proptosis

* Restricted eye movements

* Tongue or throat swelling (airway risk)

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## Diagnostic Evaluation

### Clinical Assessment

* Onset (sudden vs gradual)

* Pain, itching, redness

* Drug and allergy history

* Systemic symptoms

### Investigations

Depending on suspicion:

* CBC, CRP (infection)

* Urine protein, serum albumin (nephrotic syndrome)

* Thyroid function tests

* Renal and liver function tests

* CT/MRI orbit (if orbital cellulitis suspected)

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## Management Approach

| Cause | Treatment |

| --------------------------- | ----------------------------------- |

| Allergic edema | Antihistamines, corticosteroids |

| Angioedema with airway risk | **IM epinephrine + emergency care** |

| Nephrotic syndrome | Treat underlying renal disease |

| Thyroid disorder | Endocrine management |

| Orbital cellulitis | IV antibiotics + imaging |

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## Key Takeaway

> **Bilateral periorbital swelling is most commonly caused by allergy or systemic disease rather than infection.**

However, **red flag symptoms must never be ignored**, as conditions like orbital cellulitis and angioedema can rapidly become life-threatening.

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