Acute unilateral proptosis

A 15 month old child presented with 12 days of right sided, purulent nasal discharge and six days of progressively worsening bulging, excess fluid/tearing, and eyelid redness of the right eye. Examination revealed pronounced proptosis, chemosis, eyelid erythema, and yellow crusting in the corner of the right eye (fig 1), with no signs on the left. Pupil diameter and pupillary light reflexes were normal in both eyes. The patient was unable to cooperate with further visual examination, so it was not possible to assess visual acuity or eye movements. Three days earlier, intravenous infusion of ceftriaxone sodium had been started, as we suspected acute rhinosinusitis causing orbital inflammation, but this had no effect. The child’s temperature was 40°C, white blood cell count 18.65×10⁹/L (nomal range 4-10×10⁹/L), and a culture of the nasal discharge grew Streptococcus viridans …