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JAMA Ophthalmology Clinical Challenge
June 2017

A 64-Year-Old Man With Swollen, Blistered Eyelids

Author Affiliations
  • 1Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
  • 2Craniofacial Plastic Surgery Service, Department of Plastic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
JAMA Ophthalmol. 2017;135(6):669-670. doi:10.1001/jamaophthalmol.2016.5410

A 64-year-old man with type 2 diabetes mellitus, hypertension, hyperlipidemia, and chronic obstructive pulmonary disease fell 3 days prior to presentation, hitting the right side of his face, sustaining a small eyelid skin laceration for which he did not seek treatment. Over subsequent days, he developed right periorbital erythema, edema, and pain, with blisters appearing on the eyelid skin 1 day prior to presentation.

On examination, his pulse was 120 beats per minute, blood pressure was 92/62 mm Hg, and temperature was 38.2°C. The right upper and lower eyelids were warm, erythematous, edematous, and tender, with large fluctuant blisters (Figure, A). Erythema tracked down the cheek, and there was right cervical lymphadenopathy. The patient did not cooperate for a visual acuity assessment, but there was no afferent pupillary defect. Limited penlight examination revealed a normal anterior segment except for 360° conjunctival chemosis. Noncontrast computed tomography of the orbits demonstrated extensive right preseptal soft tissue swelling and slight enlargement of the right lateral rectus muscle with minimal orbital fat stranding. The right globe was slightly proptotic (Figure, B). Laboratory testing revealed a white blood cell count of 32.6 K/µL (to convert to × 109 per liter, multiply by 0.001), with 95% polymorphonuclear lymphocytes.

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