[Skip to Content]
[Skip to Content Landing]

Acute Unilateral Proptosis After Blunt Orbital Trauma in an Adolescent Patient

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

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.

You answered correctly!

Read the answer below and download your certificate.

You answered incorrectly.

Read the discussion below and retake the quiz.

Orbital lymphangioma

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.

Survey Complete!

Sign in to take quiz and track your certificates

Buy This Activity

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.

Article Information

Corresponding Author: Anthony P. Mai, MD, John Moran Eye Center, University of Utah, 65 Mario Cappechi Dr, Salt Lake City, UT 84132 (anthony.mai@hsc.utah.edu).

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.

References
1.
Raichura  ND , Alam  MS , Noronha  VO , Mukherjee  B .  A prospective study of the role of intralesional bleomycin in orbital lymphangioma.   J AAPOS. 2017;21(2):146-151. doi:10.1016/j.jaapos.2017.03.007PubMedGoogle ScholarCrossref
2.
Shields  JA , Shields  CL , Scartozzi  R .  Survey of 1264 patients with orbital tumors and simulating lesions: the 2002 Montgomery Lecture, part 1.   Ophthalmology. 2004;111(5):997-1008. doi:10.1016/j.ophtha.2003.01.002PubMedGoogle ScholarCrossref
3.
Wright  JE , Sullivan  TJ , Garner  A , Wulc  AE , Moseley  IF .  Orbital venous anomalies.   Ophthalmology. 1997;104(6):905-913. doi:10.1016/S0161-6420(97)30208-5PubMedGoogle ScholarCrossref
4.
Krohel  GB , Wright  JE .  Orbital hemorrhage.   Am J Ophthalmol. 1979;88(2):254-258. doi:10.1016/0002-9394(79)90474-4PubMedGoogle ScholarCrossref
5.
Patel  SR , Rosenberg  JB , Barmettler  A .  Interventions for orbital lymphangioma.   Cochrane Database Syst Rev. 2019;5(5):CD013000. doi:10.1002/14651858.CD013000.pub2PubMedGoogle ScholarCrossref
6.
Gandhi  NG , Lin  LK , O’Hara  M .  Sildenafil for pediatric orbital lymphangioma.   JAMA Ophthalmol. 2013;131(9):1228-1230. doi:10.1001/jamaophthalmol.2013.4201PubMedGoogle ScholarCrossref
7.
Wang  S , Zhang  J , Ge  W ,  et al.  Efficacy and safety of oral sildenafil in treatment of pediatric head and neck lymphatic malformations.   Acta Otolaryngol. 2017;137(6):674-678. doi:10.1080/00016489.2016.1272135PubMedGoogle ScholarCrossref
8.
Adams  DM , Trenor  CC  III , Hammill  AM ,  et al.  Efficacy and safety of sirolimus in the treatment of complicated vascular anomalies.   Pediatrics. 2016;137(2):e20153257. doi:10.1542/peds.2015-3257PubMedGoogle ScholarCrossref
9.
Saha  K , Leatherbarrow  B .  Orbital lymphangiomas: a review of management strategies.   Curr Opin Ophthalmol. 2012;23(5):433-438. doi:10.1097/ICU.0b013e3283560a99PubMedGoogle ScholarCrossref
10.
Nassiri  N , Rootman  J , Rootman  DB , Goldberg  RA .  Orbital lymphaticovenous malformations: current and future treatments.   Surv Ophthalmol. 2015;60(5):383-405. doi:10.1016/j.survophthal.2015.03.001PubMedGoogle ScholarCrossref
Close
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Close
Close

Lookup An Activity

or

My Saved Searches

You currently have no searches saved.

Close

My Saved Courses

You currently have no courses saved.

Close