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A 15-year-old girl with sudden onset proptosis
Digital Journal of Ophthalmology 2006
Volume 12, Number 5
December 12, 2006
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Adrian MacFarlane | Maidstone and Tunbridge Wells NHS Trust
andrew tatham | maidstone and tunbridge wells nhs trust, maidstone , kent, UK
Differential Diagnosis
The differential diagnosis of proptosis in children includes neoplaisa (rhabdomyosarcoma, neuroblastoma, retinoblastoma, leukemic infiltration, lymphoma), benign proliferation (capillary hemangioma, optic glioma, fibrous dysplasia), infections (cellulitis, mucocele), trauma (hematoma, carotid cavernous fistula, encephalocele), endocrine (thyroid eye disease) and developmental problems (infantile glaucoma, myopia, craniofacial dysostosis, dermoid cyst) [1,2].

A retrospective analysis by Sindhu et al examined 57 children with proptosis. Orbital cellulitis was the most common cause (22 cases), followed by thyroid eye disease (8), optic nerve glioma (8), orbital rhabdomyosarcoma (7), metastatic neuroblastoma (4), orbital neurofibroma (3) and orbital haemangioma (2) [3].

In this case, cellulitis was unlikely as the patient was afebrile, the skin was not warm and inflammatory markers were not raised. Thyroid eye disease does occur in children, and is well recognized in neonates of hyperthyroid mothers, however, in our patient the signs were asymmetrical, there was no lid lag and the extraocular muscles appeared normal on the MRI. The patient had no signs of neurofibromatosis, which may have suggested an associated optic nerve glioma. A lesion of the optic nerve or orbital apex was also unlikely as in these cases, visual acuity or ocular motility tend to be affected early. Finally rhabdomyosarcoma was considered in the differential diagnosis, however, given the childhood history of intermittent proptosis and clinical course following admission this was very unlikely [1].
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