Discoloration around the eye, the periorbital skin and eyelids, and of the eye may result from multiple causes. Children and adults with darker skin pigmentation—those of African, Asian, or Hispanic descent—may also have increased pigmentation of the bulbar conjunctivae. This discoloration is often bilateral, but may be asymmetric and patchy and most noticeable in the interpalpebral area. Conjunctival hyperemia, injection, and inflammation, inclusively referred to as conjunctivitis, can occur from numerous causes, including infection, trauma, allergies, foreign bodies in the eye, reaction to drugs or other toxins, and mechanical irritation from eyelashes and eyelids. Discoloration below the eyes can be seen with “allergic shiners,” which results from venous congestion due to sinus mucosal edema from systemic allergic inflammation. Chalazions are granulomas formed from blocked meibomian glands along the eyelash margin. They are not infectious and do not require antibiotic treatment. Cellulitis, orbital (postseptal) and periorbital (or preseptal), can cause discoloration and swelling of the periorbital skin as well as eyelids and can cause hyperemia of bulbar conjunctivae. In orbital cellulitis, the infection extends past the orbital septum, resulting in eye motility restriction, optic nerve compression and vision loss, and/or secondary extension into the central nervous system. Certain tumors can cause discoloration around and in the eyes. Neuroblastoma, a tumor of embryonic sympathetic neuroblasts typically originating in the abdomen, can cause unilateral or bilateral proptosis, periorbital swelling, and lid or infraorbital ecchymosis as part of the classic presentation for orbital metastasis. Rhabdomyosarcoma, the most common primary malignant orbital tumor in children, may present with rapidly progressive proptosis and eyelid redness not associated with localized warmth or fever, distinguishing it from cellulitis. Capillary hemangiomas are vascular orbital tumors of proliferating capillary endothelial cells. They can cause a bluish discoloration of the overlying skin or the classic strawberry mark. A nevus flammeus, or port-wine stain, which can be seen in Sturge–Weber syndrome, is a vascular malformation of dilated capillaries causing a reddish stain to the skin. Melanocytic lesions can affect conjunctiva as well as surrounding tissues of the eye and include conjunctival nevus, congenital nevocellular nevus of skin, and oculodermal melanocytosis or nevus of Ota. Conjunctival nevi may be flat or elevated and are typically brown and commonly found at the temporal and nasal limbi. Congenital nevocelluar nevus of skin, which occurs on eyelids, has potential for malignant transformation. Ocular and oculodermal melanocytosis, or nevus of Ota, causes slate-gray or bluish discoloration to sclera, and can involve eyelid and adjacent skin producing a brown, bluish, or black discoloration. Icterus is a yellow discoloration of the sclera that occurs with jaundice and results from bilirubin binding to the bulbar conjunctiva. In some connective tissue disorders such as Ehler–Danlos syndrome, Marfan syndrome, and osteogenesis imperfecta, the sclera may appear blue because of the underlying blue-brown uveal tissue (retina and ciliary body) showing through the thinner and more transparent sclera. In blunt trauma to the eye, there can be significant swelling and bruising that affect surrounding tissues.

• Itching and tearing are the hallmark of allergic eye disease. Patients will often report other allergy symptoms of rhinorrhea and nasal congestion, and a history of other atopic diseases such as asthma and eczema. A family history of atopic disease may also be reported.

• Viral conjunctivitis usually occurs in epidemic outbreaks in schools and child care settings. It may also be associated with concurrent or recent viral upper respiratory tract infections.

• Periorbital cellulitis may follow superficial eyelid trauma, conjunctivitis, skin infection, or upper respiratory tract or sinus infection.

• Orbital cellulitis in children is most commonly associated with sinus disease. A history of rapid onset of swelling, blurred vision, and double vision is common.

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