Case 4: Eye Droopiness in a 4-year-old Girl

Presentation

A 4-year-old girl with sickle cell trait presented to the emergency department (ED) with an 11-day history of redness, swelling, and droopiness of the right eye. The pediatrician initially diagnosed the child as having periorbital cellulitis, prescribed amoxicillin-clavulanic acid, and referred her to an ophthalmologist. On ophthalmologic evaluation she was found to have mild upper lid proptosis; funduscopic examination findings were normal. A maxillofacial computed tomographic (CT) scan showed normal extraocular muscles and optic nerve, with minimal subcutaneous soft tissue swelling along the right eyelid and intra-orbital fat bilaterally consistent with preseptal cellulitis.

On presentation to the ED, she had completed 7 days of antibiotic drug treatment. She had normal findings on physical examination, with no ptosis, anisocoria, afferent pupillary defect, or neurologic deficit and was discharged, with outpatient neurology follow-up the following day. At that time, she was noted to have right eye ptosis with down and out position concerning for right third nerve palsy, left eye ptosis, and left eye adduction abnormality. This examination shifted on repeated evaluation in the ED, where she had right-sided ptosis and right third cranial nerve palsy but her left ocular examination findings were normal. Her white blood cell count was 6,200/μL (6.2×10⁹/L), hemoglobin level was 11.5 g/dL (115 g/L), and platelet count was 358×10³/μL (358×10⁹/L). Her hemoglobin electrophoresis showed 35% hemoglobin S. Results of thyroid studies were normal. Findings from magnetic resonance imaging of the brain and magnetic resonance angiography of the head and neck were normal.