1. Eyelid swelling and discharge
A 13-year-old boy presents with swelling of the left eyelids
that started 12 hours earlier; the eyelashes are matted
with yellow discharge. He does not wear contact lenses or
eyeglasses and denies ocular trauma or foreign bodies. He
has been nauseated and has vomited once; his mother
attributes these symptoms to an antibiotic that was prescribed
5 days earlier for a sinus infection. Medical history
is noncontributory; there is no family history of ocular
The patient is in moderate discomfort. He complains
of blurred vision in his left eye, eye pain that worsens when
he looks to the left, left facial pain, and congestion with
greenish nasal discharge. Temperature is 38.3oC (101.1oF);
heart rate, 90 beats per minute; respiration rate, 14 breaths
per minute; blood pressure, 130/80 mm Hg; and oxygen
saturation, 97% on room air. Visual acuity on a Snellen chart
is 20/20 in the right eye and 20/70 in the left eye.
There is marked periorbital swelling of the left eye
with dried yellow discharge on the lids. Significant proptosis
of the left eye is evident when the lids are retracted,
along with mild diffuse erythema and edema of the conjunctiva.
No foreign bodies are noted either over the conjunctiva
or on the eyelids. The patient cannot perform lateral
gaze with his left eye. Pupils are equally round and
reactive to light and accommodation. Right eye is normal.
Tenderness is noted over the left maxillary sinus; the
neck is supple, with a small amount of left anterior
adenopathy. Heart, lungs, and abdomen are normal. The
patient is alert and oriented; no sensory loss is detected in
the infraorbital or supraorbital areas.
You administer intramuscular antibiotics, obtain a
sample of the eye discharge for culture, consult an ophthalmologist,
and order radiographs of the sinuses. What
do these films reveal about the cause of the patient's
symptoms, and what further investigation is warranted?