A 16-year-old male patient developed acute-onset right-sided periorbital swelling several days after being hit in that area by a snowball. The swelling worsened over the following 3 weeks despite use of warm compresses and a course of doxycycline prescribed by his outside eye care professionals. He had progressive binocular diplopia and right periorbital pain, swelling, and redness. Blurriness of the right eye that started the week before presentation eventually caused enough concern that the patient presented to his local emergency department where magnetic resonance imaging (MRI) of the brain and orbits revealed an intraconal mass (Figure, A). He then came to our institution’s emergency department for urgent ophthalmology consultation.
Please finish quiz first before checking answer.
Read the answer below and download your certificate.
Read the discussion below and retake the quiz.
D. Perform an emergency orbital exploration with lesion biopsy
The differential diagnosis of acute proptosis in an adolescent includes orbital cellulitis, abscess, orbital vascular lesion with or without intralesional hemorrhage, spontaneous orbital hematoma, traumatic carotid-cavernous fistula, orbital inflammatory syndrome, rhabdomyosarcoma, metastatic neuroblastoma, ruptured dermoid cyst, Ewing sarcoma, and leukemia-associated myeloid sarcoma.
There was no inflammation on the MRI scan to support orbital cellulitis, which would be treated by intravenous antibiotics (choice A), or orbital inflammatory syndrome, which would be treated by high-dose steroids (choice C). The patient did not have periorbital ecchymosis, which is often seen in metastatic neuroblastoma. Because 90% of neuroblastomas present in children younger than 5 years, screening for neuroblastoma via urine homovanillic and vanillylmandelic acid testing would be low yield in a 16-year-old patient (choice B). Urgent exploratory surgery (choice D) was indicated given the potential for visual compromise in the setting of decreased visual acuity, high intraocular pressures, optic disc edema, and choroidal folds.
Sign in to take quiz and track your certificates
JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 Credit(s)™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC
CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Corresponding Author: Anthony P. Mai, MD, John Moran Eye Center, University of Utah, 65 Mario Cappechi Dr, Salt Lake City, UT 84132 (firstname.lastname@example.org).
Published Online: November 17, 2022. doi:10.1001/jamaophthalmol.2022.4748
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank the patient’s mother for granting permission to publish this information.
You currently have no searches saved.
You currently have no courses saved.