A 3-year-old male comes to clinic with complaints of 2 weeks of intermittent eye swelling. The mother describes that there is slight puffiness in the lower outer corners of both eyes intermittently and that the father has also noted this. It was noticed ~5 times during the 2 weeks. There is not a time of day when it appears to occur more often. It lasts for an unknown period of time. There has been no swelling of the extremities, difficulties in putting on shoes or clothes, and no swelling of the hands or feet.
The past medical history is positive for urticaria of unknown cause several months previous.
The family history is negative for heart, kidney, liver, or oncological disease. There was hearing loss in an elderly relative.
His social history reveals that he began child care ~1 month ago.
The review of systems is negative for recent illnesses, allergic symptoms, itching, eating well with no weight loss, fevers, night sweats/chills, urinary or gastrointestinal changes, skin changes, neurological symptoms, decreased activity, and excessive bruising or bleeding.
The pertinent physical exam reveals he is well appearing with normal growth and vital signs. He has no eye or facial swelling. There is no redness or skin discoloration of eyes or face. He has no tenderness to palpation of his facial bones or eyes. The rest of his ophthalmologic exam is normal. His nose has a small amount of clear rhinorrhea. There is no boggy or discolored nasal mucosa. He has shoddy anterior cervical lymph nodes. His heart, pulmonary, and abdominal examination are normal. He has no edema of his hands, feet or scrotum. He has a few small bruises over the anterior shins. His neurological examination is normal.
The laboratory evaluation included a normal BUN, creatinine and urinalysis.
As this child’s history, physical examination and brief laboratory evaluation appear to be normal at the present time
a diagnosis of intermittent eye swelling of unknown etiology was made. The family was instructed to monitor the patient, keep a symptom diary and return if the problem persists or changes. At follow-up the patient had no further problems.
Children often present with complaints whose etiology cannot be determined at that time and watchful waiting is an appropriate course of action. Careful history and physical examination should be performed trying to exclude any serious current problem. Judicious use of laboratory testing can be helpful to include or exclude serious problems. Laboratory testing can also sometimes be helpful by providing a baseline test for future reference. Parents can be sent home with instructions to watch their child closely and report any further progression of the current complaint or additional problems. Symptom diaries often are helpful as data can be collected prospectively and then possible patterns discerned from the records. Parent should be told what symptoms to report immediately. They should also be told a general time period that the complaint probably should be resolved by or the patient should then be seen again.
The differential diagnosis of generalized eye swelling includes:
- Allergies – seasonal allergic rhinitis, urticaria, angioedema
- Heart disease
- Infection – localized infection such as preseptal or orbital cellulitis, generalized sepsis
- Liver disease
- Malnutrition – food faddism, malabsorption
- Oncologic disease – primary tumor or metastatic disease
- Ophthalmologic disease – trauma, conjunctivitis or blepharitis with rubbing
- Renal disease – renal failure, nephrotic syndrome
In children, rubbing of the eyes caused by allergies or URIs are common. Also nephrotic syndrome can present with mild periorbital edema. Chalazion and hordeolums usually cause localized swelling. Eyelid tumors such as nevi, dermoid cysts and capillary hemangioma may be localized or more generalized.
Questions for Further Discussion
1. Where is generalized body edema likely to be detected on physical examination?
2. What work-up should be considered if heart, renal or liver disease is suspected?
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for this topic: Eyelid and Tear Gland Problems.
Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:2362-2366.
Woodhead JC. Pediatric Clerkship Guide. Mosby., St. Louis MO, 2003:241-244.
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa
December 13, 2004