What is the appropriate evaluation and treatment for a 10-year-old patient experiencing bilateral retroorbital (behind the eye) pain?

Bilateral Retroorbital Pain in a 10-Year-Old Child

This child requires urgent ophthalmologic evaluation to rule out vision-threatening and life-threatening conditions, as eye pain in children is a red flag that can indicate serious ocular or systemic pathology ranging from infectious/inflammatory processes to intracranial disease. 1

Initial Clinical Assessment

Critical History Elements

• Trauma history: Determine if there was any recent head or facial trauma, as orbital injury should be suspected with periorbital swelling, vision changes, or eye movement restriction 2
• Vision changes: Document any decrease in visual acuity, diplopia, or visual field defects 2
• Associated symptoms: Ask about headache, nausea, vomiting, fever, photophobia, eye redness, or discharge 1
• Timing and character: Determine onset (acute vs. gradual), severity, and whether pain is constant or intermittent 3
• Systemic symptoms: Screen for signs of infection, autoimmune disease, or neurologic symptoms 1

Essential Physical Examination Components

• Visual acuity testing: Measure and document baseline vision in each eye separately 2
• Pupillary examination: Assess for relative afferent pupillary defect (RAPD), which may indicate optic nerve pathology 2
• Extraocular movements: Evaluate for restriction or pain with eye movement 2
• External examination: Look for periorbital swelling, erythema, proptosis, or enophthalmos 2
• Funduscopic examination: After dilation, examine the optic disc for papilledema or optic nerve abnormalities 2
• Intraocular pressure: Measure if glaucoma is suspected, though rare in this age group 2

Differential Diagnosis Framework

Vision-Threatening Emergencies (Require Immediate Action)

• Optic neuritis: Presents with retroorbital pain worsened by eye movement, decreased vision, and possible RAPD 3
• Acute angle-closure glaucoma: Rare in children but presents with severe pain, decreased vision, and elevated intraocular pressure 3
• Orbital cellulitis: Presents with pain, proptosis, restricted eye movements, and systemic signs of infection 1
• Intracranial pathology: Tumors or increased intracranial pressure can cause bilateral retroorbital pain and papilledema 4

Common Non-Emergent Causes

• Refractive error: Uncorrected hyperopia or astigmatism can cause eye strain and retroorbital discomfort 2
• Convergence insufficiency: May present with asthenopic symptoms and eye discomfort, particularly with near work 2
• Sinusitis: Can cause referred pain to the retroorbital region bilaterally 1

Imaging Recommendations

When to Image

MRI of the orbits and brain with and without contrast is the preferred initial imaging study when structural pathology is suspected, as it provides superior soft tissue characterization for masses, inflammatory processes, or optic nerve abnormalities 2

Indications for urgent neuroimaging include: 2

• Progressive vision loss
• Abnormal pupillary responses
• Papilledema on funduscopic examination
• Proptosis or restricted extraocular movements
• Associated neurologic symptoms

CT of the orbits without contrast is appropriate if trauma is suspected, as it is superior for identifying orbital fractures and bony abnormalities 2

Management Algorithm

Immediate Referral to Ophthalmology Required If:

• Any vision loss or decreased visual acuity 1, 5
• Abnormal pupillary responses or RAPD 2
• Restricted or painful extraocular movements 2
• Proptosis or significant periorbital swelling 2
• Papilledema or optic disc abnormalities 2
• Severe or progressive pain 1, 3

If Initial Examination is Reassuring:

• Cycloplegic refraction: Perform to rule out significant refractive error, using cyclopentolate 1% in children over 12 months 2
• Accommodation and convergence testing: Assess for convergence insufficiency if symptoms are related to near work 2
• Trial of refractive correction: If significant hyperopia or astigmatism is found, prescribe corrective lenses 2

Common Pitfalls to Avoid

• Assuming bilateral pain is benign: While refractive error is common, bilateral retroorbital pain can indicate serious intracranial pathology or bilateral optic nerve disease 4
• Delaying ophthalmologic consultation: Children with eye pain and any vision changes require same-day ophthalmology evaluation 1, 5
• Missing papilledema: Adequate pupillary dilation is essential for proper funduscopic examination in children 2
• Overlooking trauma history: Even minor head trauma can cause orbital injury; maintain high suspicion in children with periorbital findings 2, 6
• Inadequate pain assessment: Children may not accurately describe or localize pain; observe for behavioral changes and eye rubbing 1

Special Considerations in Pediatric Patients

Children with major trauma (ISS >15) who have ocular complaints are more likely to have orbital wall fractures, basilar skull fractures, and optic nerve injuries, requiring comprehensive evaluation even if external findings are minimal 6

Examination techniques must be age-appropriate: Younger children may require swaddling or sedation for complete examination, and cooperation for detailed testing varies by developmental stage 2