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JAMA Ophthalmology Clinical Challenge
November 5, 2020

Recurrent Subconjunctival Hemorrhage in a Child With an Orbital Mass

Author Affiliations
  • 1John A. Moran Eye Center, The University of Utah, Salt Lake City
JAMA Ophthalmol. 2021;139(1):125-126. doi:10.1001/jamaophthalmol.2020.4087

A well-appearing 14-month-old girl was referred for the evaluation of recurrent left subconjunctival hemorrhage with increasing frequency since 7 months of age. Multiple prior office visits with referring ophthalmologists during which eyes were dilated showed normal results. Clinical examination revealed 180° of left interior subconjunctival hemorrhage with overlying conjunctival elevation and mild fullness of the left lower eyelid (Figure 1A). Fixation was central, steady, and maintained bilaterally, with full ocular motility and absence of appreciable proptosis. Penlight anterior segment examination demonstrated normally formed anterior segment structures without inflammation or hyphema in either eye, although the left eye exhibited a small intraocular lightly pigmented lesion at the 5-o'clock limbus. Examination under anesthesia (EUA) was deemed appropriate and further demonstrated normal intraocular pressures bilaterally. Handheld slitlamp examination localized the left eye 2-mm limbal lesion on the posterior corneal surface. The surrounding corneal and iris structures were normal appearing without evidence of vascularization. Ultrasound biomicroscopy was used to further evaluate both the intraocular lesion and better characterize the left lower eyelid fullness. This demonstrated no iris, angle, or ciliary body involvement by the intraocular lesion. A 10-MHz contact B-scan examination showed a large inferior orbital lesion measuring more than 17 mm in the anterior-to-posterior dimension (Figure 1B). Doppler ultrasonography did not demonstrate significant flow to suggest a vascular cause.

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