Correspondence

Orbital Pseudo-Pseudotumor in a Four-Year-Old

N Engl J Med 1994; 330:1094April 14, 1994

Article

To the Editor:

We wish to describe what initially appeared to be a right orbital pseudotumor and was ultimately discovered to be an embedded conjunctival foreign body causing a granulomatous reaction.

The mother of a four-year-old noted swelling in the right upper eyelid of her daughter. At the office, we attributed the problem to allergy because there was a mild “cobblestone” appearance and slight erythema. An ophthalmic solution consisting of naphazoline hydrochloride and pheniramine maleate was prescribed. Six weeks later the patient's mother called to report that the situation had worsened and “the right eye was drooping.” An ophthalmologist identified exophthalmos of 2.5 mm in the right eye. There was no limitation of motion or strabismus. Computed tomography and magnetic resonance imaging revealed questionable enlargement of the right lateral rectus muscle, but no space-occupying lesion. It was determined that the best course of action was watchful waiting.

There was some improvement over the next few months despite mild orbital asymmetry (a difference of 0.5 mm) with ptosis. When the child was next evaluated, there was progression of her ptosis, with a movable subcutaneous orbital lesion in the right upper lid. This was the first time a definite mass could be palpated. Despite the mass, there was no limitation of extraocular motion. The ophthalmologist recommended a biopsy by anterior orbitotomy.

With the child under general anesthesia, the right upper lid was everted, revealing a small, embedded translucent object. After careful excision, a hard contact lens embedded in granulomatous tissue was removed. A review of the initial computed tomography and magnetic resonance imaging showed no indication of a lens.

On further questioning the mother recalled that she had lost a contact lens four months before the first visit. The child eventually confessed to secretly playing “mom” by inserting the mother's contact lens into her own eye. The lens was in her eye for 4 months before the first visit and for more than 13 months altogether, ultimately producing this puzzling case of contact-lens granuloma.

Bonni Field, M.D.
Ralph S. Milner, M.D.
Brian McDonough, M.D.
Demetrios Zerefos, D.O.
St. Francis Hospital, Wilmington, DE 19805-0500