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A 14-year-old girl with pain in the right eye
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A 14-year-old female was admitted to the hospital by the ophthalmology service for evaluation and treatment of swelling, erythema and pain of her right eye, particularly with eye movement. The history of this illness began when the patient was on a mission trip to Mexico and began experiencing pain in her right eye. She was seen locally and diagnosed with a corneal abrasion and treated with an antibiotic ointment, even though there was no history of injury. Two days later, she returned home and was seen in follow up at the ophthalmology clinic. There was no history of fever associated with this problem.
Her past medical history and review of systems were unremarkable except for the chief complaint. Her immunizations were up to date.
Pediatric Infectious Disease, Scott and White's Children's Health Center and Associate Professor of Pediatrics,
Texas A&M University, College of Medicine, Temple, Texas.
e-mail: jhbrien@aol.com
Her examination revealed normal vital signs with mild erythema and swelling of the periorbital soft tissues of the right eye, as show in Figure 1. There was also some restricted gaze of that eye, as shown in figure 2, along with conjuctival erythema, as shown in figure 3. The rest of her examination was normal.
No lab tests were done. A CT scan is shown in figure 4.
What’s Your Diagnosis?
- Postseptal cellulitis
- Orbital encephalocele
- Preseptal cellulitis
- Orbital pseudotumor
Answer
The answer is D, orbital pseudotumor. Now, you’re probably wondering, “what in the world is orbital pseudotumor”? That was certainly my initial response. Before this patient, I had never seen nor heard of this condition. Also known as idiopathic orbital inflammatory syndrome, the etiology of which is unknown, it is apparently seen by ophthalmologists on a regular basis, but is relatively uncommon in pediatric patients. The definition is a swelling of any tissues within the orbit. There are several histological classifications (granulomatous, eosinophilic, vasculitis and sclerosing), based on biopsy results, however, the majority are treated without tissue diagnosis. The cause is unknown and it is generally seen in young women, usually affecting only one eye. The main complaint is pain, but the patient can also have decreased vision, and on examination they can demonstrate mild-to-moderate swelling of the lids, as shown in this patient. The eye may have some erythema, but this may be absent. The case presented is relatively mild; however some cases can result in proptosis and loss of vision. On CT imaging, a mass is seen, which may be within the rectus, as shown in this patient. The main thrust of therapy is with high-dose corticosteroids.
Preseptal cellulitis is a relatively common condition; usually caused by minor injury to the periorbital soft tissue with a break in the skin (figure 5), which may be very small, and not be noticed. There may be fever with this condition, especially if there is an abscess associated with it (figure 6). By definition, these infections are outside the orbital septum, and can often be treated with oral antibiotics with close outpatient follow up. If that’s the case, and there is a break in the skin, I would recommend using clindamycin since the majority is caused by Staphylococcus aureus, and one must consider MRSA. If the patient is sick enough for intravenous antibiotics, one may need to consider vancomycin. In that case, I would also add a third-generation cephalosporin as well. In the days when Haemophilus influenzae type b was common, periorbital infections were a common location for this hematogenously spread infection.
Postseptal (orbital) cellulitis refers to infections in the structures behind the orbital septum. These are often complicated by ethmoid sinusitis as shown in figure 7, revealing the sinusitis as well as a subperiosteal abscess of the lamina papyracea. These infections always need hospital admission, IV antibiotics and usually surgical drainage. Patients with this are usually sick with fever as opposed to those with orbital pseudotumor, who are usually complaining only of eye pain.
An orbital encephalocele is a rare congenital anatomic defect that may present in a similar fashion as an orbital pseudotumor. However, it may be characterized by recurrent symptoms depending on the size of the defect. A young child presented with recurrent, very subtle swelling of the left upper lid, eventually getting him admitted for evaluation. His MRI revealed the defect that is shown in the T2 images in figures 8 & 9, extending from deep within the base of the brain to the area next to the left lateral rectus. Of course, the treatment for this is surgical.
Columnist Comments
I would like to remind you about the 43rd Annual Uniformed Services Pediatric Seminar, to be held in Indianapolis, Indiana March 8–11. If you’re looking for a good, AAP-sponsored CME activity, go to http://www.aap.org/sections/uniformedservices/2009USPSBrochure.pdf for details.
What’s Your Diagnosis? is a monthly case study featured in Infectious Diseases in Children, with treatment information and discussion to follow.