The etiology of swelling of/around the eye ranges from benign, temporary irritation to more serious ophthalmological emergencies. Preseptal swelling can be broadly divided into two categories: conditions with diffuse swelling and those with discrete swelling. Diffuse swelling may be due to edema from localized extravasation of the capillary fluid as seen in allergies, or from hypoalbuminemia associated with nephrotic syndrome or reduced cardiac output. Discrete swelling results from growths such as hemangiomas, occlusion of the nasolacrimal duct system, or inflammation or infection of eyelid glands as seen with a hordeolum.

• Preseptal cellulitis often occurs after an insult to skin integrity as seen with an insect bite. Timing of the swelling in relation to timing of the bite helps distinguish between a superimposed infection and a simple bite. Generally, bacterial infections do not set in until 2 to 3 days after the initial bite.

• Preseptal cellulitis is often preceded by a history of a bacterial infection such as acute otitis media or sinusitis.

• In cases of IgE-mediated allergic reactions, consider not only airborne allergens but also contact irritants from substances rubbed into the eye. Sunscreen or lotion is a common irritant. Food allergies are unlikely to cause isolated, unilateral periorbital swelling.

• A history of pruritus suggests allergy; however, allergy-induced swelling can be deceivingly nonpruritic.

• Cardiac failure patients may report dyspnea or diaphoresis on exertion (e.g., infants during feeding, older children during exercise), orthopnea, nocturnal dyspnea, cyanosis, or respiratory distress. Look also for a history of failure to thrive.

• A history of abdominal pain may be associated with Henoch–Schönlein purpura (HSP) and hereditary angioedema.

• An intermittent history of swelling may be associated with hereditary angioedema (plasma protein C1 inhibitor deficiency). Tingling in the area may precede swelling.

• Sudden appearance of a tender eyelid mass suggests a hordeolum.

• Chalazia are generally painless and can be present for weeks prior to presentation.

• Hemangiomas and lymphangiomas often appear the same on physical examination. However, hemangiomas are not present at birth and tend to be more rapidly growing than lymphangiomas. Approximately half of all lymphangiomas are present at birth.

• Unilateral diffuse swelling results from localized extravasation of the capillary fluid into the periorbital area in association with allergic, infectious, or traumatic causes.

• The presence of fever or tenderness on examination points toward infection. This is particularly important to note when differentiating between an insect bite and periorbital cellulitis. In periorbital cellulitis, look for the presence of other bacterial infections such as acute otitis media or sinusitis.

• Signs of orbital infection include proptosis, restriction of extraocular movements (usually inability to look up), visual changes, and pain with eye movement. Systemic symptoms such as fever, drowsiness, vomiting, or headache may be present and should raise the suspicion for bacteremia, meningitis, or brain abscess.

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