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A well-appearing 14-month-old girl was referred for the evaluation of recurrent left subconjunctival hemorrhage with increasing frequency since 7 months of age. Multiple prior office visits with referring ophthalmologists during which eyes were dilated showed normal results. Clinical examination revealed 180° of left interior subconjunctival hemorrhage with overlying conjunctival elevation and mild fullness of the left lower eyelid (Figure 1A). Fixation was central, steady, and maintained bilaterally, with full ocular motility and absence of appreciable proptosis. Penlight anterior segment examination demonstrated normally formed anterior segment structures without inflammation or hyphema in either eye, although the left eye exhibited a small intraocular lightly pigmented lesion at the 5-o'clock limbus. Examination under anesthesia (EUA) was deemed appropriate and further demonstrated normal intraocular pressures bilaterally. Handheld slitlamp examination localized the left eye 2-mm limbal lesion on the posterior corneal surface. The surrounding corneal and iris structures were normal appearing without evidence of vascularization. Ultrasound biomicroscopy was used to further evaluate both the intraocular lesion and better characterize the left lower eyelid fullness. This demonstrated no iris, angle, or ciliary body involvement by the intraocular lesion. A 10-MHz contact B-scan examination showed a large inferior orbital lesion measuring more than 17 mm in the anterior-to-posterior dimension (Figure 1B). Doppler ultrasonography did not demonstrate significant flow to suggest a vascular cause.
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C. Examine the abdomen during the EUA
The differential diagnosis of an orbital mass in a toddler includes dermoid cyst, infantile hemangioma, subperiosteal hematoma, orbital abscess, rhabdomyosarcoma, leukemia (chloroma), neuroblastoma, venous-lymphatic malformation, histiocytosis, and infantile fibromatosis.1 Aspiration of the lesion (choice A) would be useful in an abscess or a cystic lesion but not in a solid tumor. Ordering orbital magnetic resonance imaging would be a better choice than computed tomography (choice B) because of radiation concerns in a child. Referring the patient for an orbital biopsy (choice D) would be appropriate but could delay treatment in a potentially life-threatening lesion. An abdominal examination (choice C) detected a mass and immediately directed subsequent diagnostic testing and treatment because of the high probability of a metastatic neuroblastoma.
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Corresponding Author: Roger P. Harrie, MD, John A. Moran Eye Center, The University of Utah, 65 Mario Capecchi Dr, Salt Lake City, UT 84132 (firstname.lastname@example.org).
Published Online: November 5, 2020. doi:10.1001/jamaophthalmol.2020.4087
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank the patient’s family for granting permission to publish this information.
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