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Endgames Picture Quiz

A rapidly enlarging swelling of the left orbit

BMJ 2015; 350 doi: (Published 25 February 2015) Cite this as: BMJ 2015;350:h799
  1. Rachel S Varughese, foundation doctor1,
  2. Elliott Ridgeon, foundation doctor1,
  3. Anna Mathew, consultant paediatrician2,
  4. David Sola-Del Valle, senior ophthalmology resident3
  1. 1University of Oxford Medical School, Oxford OX1 2JD, UK
  2. 2Department of Paediatrics, Worthing Hospital, Worthing, UK
  3. 3Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
  1. Correspondence to: R S Varughese rachel.varughese{at}

A previously well 16 year old girl presented to acute medical admissions (walk-in assessment clinic) with a one week history of swelling of her left eyelid. She was prescribed amoxicillin for a presumed folliculitis.

She re-presented one week later to the emergency department because the swelling had steadily worsened over the past two weeks. It was tender to palpation but there was no pain with movement. Visual acuity was reduced in the left eye to 6/9 (previously 6/6), and although the swelling appeared to push her left eye “down and to the side” she denied diplopia. Pupils were equal and reactive, and the conjunctiva on the left was mildly injected superonasally. Her eye movements were normal. She had no history of trauma, insect bites, fever, or fatigue. Blood test results were unremarkable.

Her medical history consisted of two right eyebrow cysts removed six years earlier. Family history included a mother with three basal cell carcinomas and a maternal grandmother with chronic lymphocytic leukaemia.

She had no history of alcohol, smoking, or illicit drug use. In the emergency department she was given a second course of systemic antibiotics and scheduled for a follow-up appointment in the ophthalmology clinic nine days later.

In clinic, her visual acuity had drastically decreased to 6/60, the mass had increased in size and felt fluctuant, and her upgaze was now restricted (fig 1).


  • 1. What differential diagnoses should have been considered at first presentation?

  • 2. What is the most likely diagnosis in this age group?

  • 3. What important investigations are needed?

  • 4. What are the management options?

  • 5. What is the prognosis of this condition?


1. What differential diagnoses should have been considered at first presentation?

Short answer

An orbital mass carries a wide differential diagnosis, with three main categories: infectious causes, orbital tumours, and inflammatory lesions.

Long answer

Eye “lumps” are poorly understood by non-specialists so important diagnoses can …

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