Journal of Pediatric Ophthalmology and Strabismus

Images in Pediatric Ophthalmology 

Painful Proptosis in a 12-Year-Old Boy

Jamie H. Choi, BA; Wasim A. Samara, MD; Adam E. Pflugrath, MD; William H. Benson, MD

Abstract

A previously healthy 12-year-old boy presented 6 days after suffering blunt trauma to the right periorbital region. He initially complained of only mild pain but later developed right periorbital swelling and headaches. On examination, his uncorrected visual acuity at near was 20/50 and 20/25 in the right and left eyes, respectively. His extraocular motility was limited to −3 in all directions on the right, but full on the left. The right eye was proptotic in addition to severe upper eyelid edema, erythema, and 360 degrees of nonhemorrhagic chemosis with prolapsed conjunctiva. A computed tomography (CT) scan of the orbit with contrast showed a dilated right superior ophthalmic vein (Figure 1A) with right-sided proptosis, orbital fat stranding, and ethmoid sinusitis (Figure 1B). Nasal aspirate cultures revealed scant growth of Staphylococcus aureus. Blood analysis showed an elevated white blood cell count of 13,600/µL (82.2% neutrophils, 10.5% lymphocytes, and 7.1% monocytes). He was discharged with a 12-week supply of oral amoxicillin-clavulanate and enoxaparin. At his 3-week follow-up visit, extraocular motility was full with a corrected visual acuity of 20/20 in both eyes. Repeat imaging showed resolution of the orbital cellulitis and significant reduction in the size of the right superior ophthalmic vein. Although rare, the diagnosis of superior ophthalmic vein thrombosis (SOVT) should be considered in patients who present with painful proptosis, chemosis, periorbital edema, and ophthalmoplegia.1 SOVT is assessed by imaging, preferably via contrast-enhanced CT scan or magnetic resonance imaging.2 The most common cause of septic SOVT is paranasal sinusitis.2 Aseptic causes include anatomic constraints, inflammation, hematologic abnormalities, and, rarely, trauma.2,3 Although this patient did have a history of blunt ocular trauma, it is unclear whether or not his sinusitis was either exacerbated or precipitated by this event. The goal of treatment is to prevent SOVT progression to cavernous sinus thrombosis, which can lead to rapid neurologic deterioration, permanent blindness, or death. Patients should begin an empiric treatment with broad-spectrum antibiotics while awaiting final culture results. Systemic anticoagulation therapy is recommended for all patients.2,4

A previously healthy 12-year-old boy presented 6 days after suffering blunt trauma to the right periorbital region. He initially complained of only mild pain but later developed right periorbital swelling and headaches. On examination, his uncorrected visual acuity at near was 20/50 and 20/25 in the right and left eyes, respectively. His extraocular motility was limited to −3 in all directions on the right, but full on the left. The right eye was proptotic in addition to severe upper eyelid edema, erythema, and 360 degrees of nonhemorrhagic chemosis with prolapsed conjunctiva. A computed tomography (CT) scan of the orbit with contrast showed a dilated right superior ophthalmic vein (Figure 1A) with right-sided proptosis, orbital fat stranding, and ethmoid sinusitis (Figure 1B). Nasal aspirate cultures revealed scant growth of Staphylococcus aureus. Blood analysis showed an elevated white blood cell count of 13,600/µL (82.2% neutrophils, 10.5% lymphocytes, and 7.1% monocytes). He was discharged with a 12-week supply of oral amoxicillin-clavulanate and enoxaparin. At his 3-week follow-up visit, extraocular motility was full with a corrected visual acuity of 20/20 in both eyes. Repeat imaging showed resolution of the orbital cellulitis and significant reduction in the size of the right superior ophthalmic vein. Although rare, the diagnosis of superior ophthalmic vein thrombosis (SOVT) should be considered in patients who present with painful proptosis, chemosis, periorbital edema, and ophthalmoplegia.1 SOVT is assessed by imaging, preferably via contrast-enhanced CT scan or magnetic resonance imaging.2 The most common cause of septic SOVT is paranasal sinusitis.2 Aseptic causes include anatomic constraints, inflammation, hematologic abnormalities, and, rarely, trauma.2,3 Although this patient did have a history of blunt ocular trauma, it is unclear whether or not his sinusitis was either exacerbated or precipitated by this event. The goal of treatment is to prevent SOVT progression to cavernous sinus thrombosis, which can lead to rapid neurologic deterioration, permanent blindness, or death. Patients should begin an empiric treatment with broad-spectrum antibiotics while awaiting final culture results. Systemic anticoagulation therapy is recommended for all patients.2,4

References

  1. Singh K, Gaindh D, Mustafa G, Kamal H, Mowla A. Spontaneous superior ophthalmic vein thrombosis: a case report (P6.227). Neurology. 2015;84(14)(suppl). http://n.neurology.org/content/84/14_Supplement/P6.227.
  2. van der Poel NA, de Witt KD, van den Berg R, de Win MM, Mourits MP. Impact of superior ophthalmic vein thrombosis: a case series and literature review. Orbit. 2019;38(3):226–232. doi:10.1080/01676830.2018.1497068 [CrossRef]
  3. Akingbola OA, Shar B, Singh D, Frieberg E, Petrescu M. Posttraumatic superior ophthalmic vein thrombosis in a 2 years old. Pediatr Emerg Care. 2014;30(2):108–110. doi:10.1097/PEC.0000000000000066 [CrossRef]
  4. Kumar JB, Colón-Acevedo B, Liss J. Diagnosis and management of superior ophthalmic vein thrombosis. EyeNet Magazine. https://www.aao.org/eyenet/article/diagnosis-management-of-superior-ophthalmic-vein-t#disqus_thread. Published May 2015.
Authors

From the School of Medicine (JHC) and the Department of Ophthalmology (WAS, AEP, WHB), Virginia Commonwealth University Health System, Richmond, Virginia.

The authors have no financial or proprietary interest in the materials presented herein.

Correspondence: William H. Benson, MD, 401 N. 11th Street, Suite 439, Richmond, VA 23298-0438. E-mail: william.benson@vcuhealth.org

10.3928/01913913-20200115-01

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