July 2014 Wills Eye Resident Case Series

Recent eyelid swelling appears to be resolved after an ER visit, but soon returns accompanied by headaches and eye pain.

Christine Talamini, MD
7/7/2014

Presentation

A 19-year-old man presented to the Wills Eye Hospital Emergency Room for evaluation of intermittent right upper eyelid swelling that had been occurring for approximately one month. He noted temporary improvement with hot and cold compresses, but persistent recurrence.  The swelling was accompanied by occasional tearing and blurry vision in the right eye. He denied history of prior trauma, recent insect bites or use of new facial products or detergents. His ocular exam was only notable for floppy eyelids and blepharitis, and he was prescribed erythromycin ointment at bedtime in both eyes, as well as warm compresses. At his two week follow-up appointment, the swelling was nearly completely resolved. The patient mentioned at this time that he was experiencing right-sided headaches, and he was referred to his primary-care provider for further evaluation. Five weeks after his initial presentation, the patient presented with recurrence of the right upper eyelid swelling, which had rapidly progressed over three days. He also reported right-sided periorbital pain, and new diplopia on upgaze.  

Medical History

The patient had no prior ophthalmic history. He had chronic anxiety and underwent surgical repair of an umbilical hernia as an infant. He was not on any chronic medications. Family history was significant for glaucoma in his paternal grandmother. He reported occasional marijuana use, but did not smoke cigarettes or drink alcohol.

Examination

Visual acuity was 20/25 in the right eye, 20/20 in the left eye. Pupils were briskly reactive in both eyes with no afferent pupillary defect. Color vision was full in both eyes. Ocular motility was full, and visual fields were full to confrontation in both eyes. Intraocular pressure was within normal limits. There was significant swelling of the right upper eyelid, as well as suggestion of hypoglobus in the right eye.



What is your differential diagnosis? What further workup would you pursue? 
Please click this link for diagnosis, workup, treatment and discussion.