Orbital venolymphatic malformation with acute intralesional hemorrhage
B. Obtain computed tomographic scan of the orbits
The differential diagnosis for orbital masses in children differs from that in adults and includes dermoid cyst, vascular malformation, optic nerve glioma, rhabdomyosarcoma, and orbital metastasis. Neuroimaging modalities, such as MRI or computed tomography (CT), can be very helpful in differentiating among these lesion types. This patient’s MRI, however, did not show distinguishing features to assist in narrowing the differential diagnosis. It would be inappropriate to observe a new and undifferentiated orbital mass that could potentially be life threatening, vision threatening, or both (choice A). As recommended by the neuroradiology service, CT scanning was performed to further characterize the mass and make an accurate diagnosis (choice B). Although biopsy is the criterion standard for diagnosis, multimodal imaging can sometimes accurately identify a benign mass and make an invasive biopsy unnecessary (choice C). This minimizes the risk of complications such as hemorrhage, which is especially true in vascular lesions. Aggressive treatment with chemotherapy and radiotherapy should not be initiated until after a diagnosis is established because these treatments are appropriate only for certain malignant lesions, such as rhabdomyosarcoma, optic nerve glioblastoma, and orbital metastasis (choice D).