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| CLINICAL QUIZ |
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| Year : 2018 | Volume
: 11
| Issue : 3 | Page : 303 |
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Child presenting with ocular ecchymosis
Sweta Singh1, Jaidrath Kumar2, Ankit Abhishek1
1 Chandigarh Laser Eye Center, Faridabad, Haryana, India
2 Department of Ophthalmology, Sarvodaya Hospital and Research Center, Faridabad, Haryana, India
| Date of Web Publication | 29-Oct-2018 |
Correspondence Address:
Dr. Sweta Singh
Chandigarh Laser Eye Center, Faridabad, Haryana
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ojo.OJO_181_2018
How to cite this article:
Singh S, Kumar J, Abhishek A. Child presenting with ocular ecchymosis. Oman J Ophthalmol 2018;11:303 |
A 10-month-old male child presented in our pediatric ophthalmology clinic with “raccoon eyes,” subconjunctival hemorrhage, proptosis [Figure 1]a, and swelling around both ears [Figure 1]b. The mother informed that the infant had been very irritable for 1 week and had developed this symptom recently which has been rapidly progressive. | Figure 1: (a) Ecchymosis of right eye with subconjunctival hemorrhage and proptosis with swelling in front of right ear. (b) Swelling behind left ear
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 Questions | |  |
- What is the differential diagnosis?
- What are the investigations required?
Answers for Clinical Quiz
 View Answer
[TAG:2]Answers[/TAG:2] Answer 1- Periorbital trauma
- Surgery
- Neuroblastoma
- Rhabdomyosarcoma
- Leukemia
- Amyloidosis
- Multiple myeloma
- Vascular malformation (hemangiomas, orbital varices, and lymphangiomas).
Answer 2Complete blood count, peripheral blood smears, serum electrolytes, coagulation studies, renal and liver function tests, and computed tomography of the orbits. | Investigations | | |
Computed tomography of the head and orbit revealed lytic destruction of bones with hair on end-type periosteal new bone formation and also soft-tissue mass causing mass effect on globe [Figure 2]a. A mass lesion was also seen in left lateral ventricle [Figure 2]b, suggesting metastasis from small round cell tumor (neuroblastoma). Abdominal ultrasound showed heteroechoeic soft-tissue mass lesion of size 4.5 cm × 4.13 cm in the left suprarenal region displacing left kidney inferolaterally. The infant had low hemoglobin count of 6 g/dl.  | Figure 2: (a) Noncontrast computed tomography head showing large mass in
fronto-parietal and parieto-occipital region. (b) Noncontrast computed tomography
head showing mass lesion in left lateral ventricle
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| Discussion | | |
Ecchymosis presenting to an ophthalmologist could be commonly due to surgery or trauma. However, if these causes are ruled out, it could be due to some serious health conditions such as amyloidosis, multiple myeloma, or neuroblastoma. Neuroblastoma is a childhood malignancy with an incidence of about 9 per million children. Among them, around 10%–20% of children have orbital metastasis. [1],[2] Ophthalmic manifestations of neuroblastoma are well documented and most commonly present as periorbital ecchymosis, subconjunctival hemorrhage, proptosis, mobility defect, ptosis, opsoclonus, and Horner's syndrome. However, ophthalmic manifestation according to the International Neuroblastoma Staging System signifies Stage 4 disease. [3] As ophthalmologists, we should be vigilant and keep all possible etiological factors in differential diagnosis so that there is no delay in diagnosis and management. Treatment involves aggressive chemotherapy followed by attempts to remove the primary tumor. After recovery, patients are started on oral 13-cis-retinoic acid for around 6 months. [4]
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's parents have given their consent for his images and other clinical information to be reported in the journal. The patient's parents understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Belgaumi AF, Kauffman WM, Jenkins JJ, Cordoba J, Bowman LC, Santana VM, et al. Blindness in children with neuroblastoma. Cancer 1997;80:1997-2004.  |
| 2. | DuBois SG, Kalika Y, Lukens JN, Brodeur GM, Seeger RC, Atkinson JB, et al. Metastatic sites in stage IV and IVS neuroblastoma correlate with age, tumor biology, and survival. J Pediatr Hematol Oncol 1999;21:181-9. |
| 3. | Brodeur GM, Seeger RC, Barrett A, Berthold F, Castleberry RP, D'Angio G, et al. International criteria for diagnosis, staging, and response to treatment in patients with neuroblastoma. J Clin Oncol 1988;6:1874-81. |
| 4. | Ahmed S, Goel S, Khandwala M, Agrawal A, Chang B, Simmons IG, et al. Neuroblastoma with orbital metastasis: Ophthalmic presentation and role of ophthalmologists. Eye (Lond) 2006;20:466-70. |
[Figure 1], [Figure 2]
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