A Teenager With Right-Eye Swelling

Honey H. Herce, MD; Kimberly G. Yen, MD


August 07, 2014

Clinical Presentation

A 17-year-old boy with no past medical history presented with a 1-day history of swelling in the right eye. The patient reported having headaches for the past 3 days. He was seen at an outside hospital and was prescribed azithromycin for suspected sinusitis. The patient reported that the headache did not resolve and that he woke up with right-eye swelling the next day.

At presentation, the patient's eye was painful, with tearing but no other discharge. He denied any changes in his vision or double vision. He also denied any trauma or insect bites. The patient had no family history of childhood eye diseases.

On ocular examination, the patient's visual acuity was 20/125 in the right eye without his glasses at distance and 20/25 at near. Visual acuity of his left eye was 20/150 without his glasses at distance and 20/20 at near. Pupils were both reactive with no relative afferent pupillary defect. He had a 3+ swelling of the right upper lid, causing ptosis. A right hypotropia and a right exotropia were present.

The patient had 9 mm of proptosis of the right eye measured by Hertel exophthalmometer (Figure 1). His motility had limitations in all fields of gaze (Figure 2). Examination of the anterior segment was significant for conjunctival chemosis and injection of the right eye. Posterior examination was normal in both eyes, with no optic nerve edema.

Figure 1. Anterior examination showing proptosis of the right eye with conjunctival chemosis and injection.

Figure 2. Motility examination shows limitations in all fields of gaze.

CT of the brain was done, followed by MRI of the brain and orbits with and without contrast (Figure 3). An abscess with a complex appearance was revealed in the right superomedial orbit associated with severe proptosis and edema. The patient also had moderate paranasal sinus disease in the frontal sinuses with dural enhancement near the right frontal pole.

Figure 3. MRI of the brain and orbits with contrast.


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