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Emergency Medicine

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

JAMA Ophthalmology

Published Online: November 17, 2022

JAMA Ophthalmology Clinical Challenge

Article Information and Disclosures

Anthony P. Mai, MD¹;

Edward P. Quigley III, MD, PhD¹;

Roger P. Harrie, MD¹

Author Affiliations

¹John Moran Eye Center, University of Utah, Salt Lake City

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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.

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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.

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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

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Patel SR , Rosenberg JB , Barmettler A . Interventions for orbital lymphangioma. Cochrane Database Syst Rev. 2019;5(5):CD013000. doi:10.1002/14651858.CD013000.pub2 PubMed Google Scholar Crossref

Gandhi NG , Lin LK , O’Hara M . Sildenafil for pediatric orbital lymphangioma. JAMA Ophthalmol. 2013;131(9):1228-1230. doi:10.1001/jamaophthalmol.2013.4201 PubMed Google Scholar Crossref

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:10.1080/00016489.2016.1272135 PubMed Google Scholar Crossref

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.2015-3257 PubMed Google Scholar Crossref

Saha K , Leatherbarrow B . Orbital lymphangiomas: a review of management strategies. Curr Opin Ophthalmol. 2012;23(5):433-438. doi:10.1097/ICU.0b013e3283560a99 PubMed Google Scholar Crossref

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.2015.03.001 PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.