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The Problem
“My child’s eye is bulging.”
Common Causes
Orbital tumors
Orbital cellulitis
Orbital lymphangioma
Orbital pseudotumor
Infantile glaucoma
Other Causes
High myopia
Craniofacial malformations
Thyroid opthalmopathy
Capillary hemangioma
KEY FINDINGS
History
Diplopia may occur with any of these lesions
Decreased vision more common with rapidly growing lesions
Orbital tumors
Rhabdomyosarcoma—rapid painless proptosis
Optic nerve glioma—may present rapidly
More common in patients with neurofibromatosis
Other tumors—gradual proptosis
Orbital cellulitis
Pain, fever, systemic illness
Rapid onset
History of sinus disease
Lymphangioma
Rapid-onset proptosis if acute bleeding
Orbital pseudotumor
Pain, worse with eye movement
Often systemic symptoms (fever, malaise)
Infantile glaucoma
Excess tearing
Light sensitivity (photophobia)
Examination
All lesions with proptosis may have limited eye movements, decreased vision, and conjunctival swelling
Orbital tumor
Often nontender proptosis
Orbital cellulitis
Periocular erythema and edema
Abnormal pupil reactions
Lymphangioma
Usually subtle proptosis unless acute hemorrhage
Acute hemorrhage may produce marked proptosis and swelling
Orbital pseudotumor
Pain with eye movement
Inflammation over extraocular muscles
Infantile glaucoma
Cornea enlarged, may be cloudy
Overflow tearing
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Children with new-onset proptosis should be referred promptly to a pediatric ophthalmologist. The differential diagnosis includes several life- and vision-threatening disorders.

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What Shouldn’t Be Missed

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Proptosis is a serious condition that requires prompt evaluation and treatment. In particular, patients with decreased vision or signs of orbital cellulitis should be referred immediately.

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  • 1. Orbital tumors. The most common primary orbital tumor in children is rhabdomyosarcoma, which classically presents with rapid onset of painless proptosis (Figure 15–1). Optic pathway gliomas affecting the optic nerve sometimes present with rapid onset of proptosis due to mucinous degeneration. Metastatic lesions, including neuroblastoma, leukemia, and lymphoma, are less common.
  • 2. Orbital cellulitis. Orbital cellulitis is a serious infection that most commonly results from contiguous spread of sinus disease (Figure 15–2). Prompt treatment with intravenous antibiotics is indicated. Orbital cellulitis is frequently associated with subperiosteal orbital abscesses, which may improve with antibiotics and not require surgical drainage.
  • 3. Lymphangioma. Lymphangiomas are congenital lesions that may not be noticed initially. These lesions are prone to internal hemorrhage, which presents with the rapid onset of proptosis (Figure 15–3). This may be difficult to distinguish from an orbital tumor without a biopsy.
  • 4. Orbital pseudotumor. Orbital pseudotumor is an idiopathic condition characterized by inflammation of the orbital tissue. It is often preceded by a systemic febrile illness, and presents with marked periocular pain. It may be localized to the extraocular muscles (myositis). It characteristically responds very promptly to systemic corticosteroid treatment.
  • 5. Infantile glaucoma. Although not an orbital disorder, glaucoma that presents in infancy or early childhood may cause enlargement of the eyeball, with a clinical appearance similar to proptosis (Figure 15–4). Affected children often have cloudy corneas and excess tearing due to corneal irritation.
  • 6. Other causes. Apparent proptosis may result from underlying abnormalities of the orbit ...

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