What is the best course of action for a 10-year-old female presenting with left anterior headache, pressure behind the eyes, blurred vision, and double vision, despite being given Bendryl (Diphenhydramine) and Toradol (Ketorolac)?

Urgent Neuroimaging and Ophthalmology Consultation Required

This 10-year-old with persistent unilateral headache, pressure behind the eyes, blurred vision, and double vision despite treatment represents a neurological and ophthalmologic emergency requiring immediate MRI of the orbits and brain with contrast, followed by urgent ophthalmology evaluation to rule out life-threatening conditions including orbital mass, cavernous sinus pathology, or acute angle-closure glaucoma. 1, 2

Critical Red Flags Present

This presentation contains multiple concerning features that mandate urgent imaging before any additional symptomatic treatment:

• New-onset headache with visual symptoms (blurred vision and double vision) in a pediatric patient requires neuroimaging as the mandatory first diagnostic step to exclude secondary causes such as intracranial mass, cavernous sinus pathology, or other life-threatening conditions 2
• Disconjugate gaze presenting as double vision suggests orbital asymmetry and potential mass lesion within the globe, optic nerve, adjacent orbital soft tissues, or skull base 1
• Pressure behind the eyes with blurred vision may indicate ocular-motor dysfunction, which can be triggered by structural lesions affecting the visual system 1
• Failure to respond to standard acute treatment (diphenhydramine and ketorolac) over 3 days suggests this is not a simple migraine and warrants investigation for secondary causes 3, 2

Immediate Diagnostic Workup

Primary Imaging Study

• MRI of the orbits without and with contrast is the optimal imaging modality to localize and characterize lesions within the globe, optic nerve, orbital soft tissues, or adjacent skull base in patients with proptosis, visual symptoms, or suspected mass lesion 1
• Add MRI of the head without and with contrast to assess extent of intracranial disease and evaluate for distant intracranial involvement 1
• MRI provides superior soft tissue characterization compared to CT and is essential for evaluating orbital inflammatory conditions, vascular malformations, and neoplastic processes 1

Urgent Ophthalmology Consultation

• Immediate ophthalmology evaluation is essential for any patient presenting with blurred vision, double vision, and pressure behind the eyes, as these symptoms may indicate vision-threatening conditions requiring specialized assessment 1
• Ophthalmologic examination should include slit-lamp examination, intraocular pressure measurement, visual acuity testing, and assessment for ocular-motor dysfunction including saccades, smooth pursuit, convergence, and accommodation 1
• Acute angle-closure glaucoma must be excluded, as it can present with severe headache, blurred vision, and pressure behind the eyes, with intraocular pressures potentially reaching 60-72 mmHg 4, 5

Differential Diagnosis Considerations

High-Priority Life-Threatening Conditions

• Orbital or intracranial mass lesion causing unilateral symptoms with pressure effects on the optic nerve and extraocular structures 1
• Cavernous sinus pathology including carotid-cavernous fistula, which may present with proptosis, orbital congestion, diplopia, and pain 1, 6
• Acute angle-closure glaucoma, which can present with severe headache, blurred vision, photophobia, and vomiting, particularly in the setting of recent medication use 4, 5, 7

Medication-Related Considerations

• Diphenhydramine has anticholinergic properties that can precipitate acute angle-closure glaucoma in susceptible individuals by causing pupillary dilation 5, 7
• This risk persists even after discontinuing the medication, making urgent ophthalmologic evaluation critical 4

Management Algorithm

Step 1: Immediate Actions (Within 1 Hour)

• Obtain urgent MRI of orbits and brain with contrast 1, 2
• Arrange immediate ophthalmology consultation for comprehensive eye examination including intraocular pressure measurement 1
• Hold all medications pending diagnostic workup 2

Step 2: Based on Imaging and Ophthalmology Findings

If structural lesion identified:

• Neurosurgery or neuro-ophthalmology consultation for definitive management 1
• Treatment directed at underlying pathology (mass resection, vascular intervention, etc.) 1, 6

If acute angle-closure glaucoma confirmed:

• Immediate treatment with intravenous acetazolamide 500 mg, topical β-blocker, α-agonists, pilocarpine 2%, and dexamethasone 0.1% 5
• Urgent peripheral iridotomy 4, 5

If ocular-motor subtype concussion identified:

• Specialized vision therapy addressing convergence, accommodation, and saccadic dysfunction 1
• Avoid activities that exacerbate visual symptoms (screen time, reading, complex visual environments) 1

If imaging negative and ophthalmology examination normal:

• Consider alternative diagnoses including migraine with aura, but only after excluding secondary causes 3, 2

Critical Pitfalls to Avoid

• Never provide additional symptomatic treatment before completing neuroimaging in a pediatric patient with new-onset headache and visual symptoms, as this delays diagnosis of potentially life-threatening conditions 2
• Do not assume this is migraine simply because the patient received typical migraine medications (ketorolac); the 3-day duration without improvement and presence of double vision mandate investigation for secondary causes 3, 2
• Do not overlook medication-induced acute angle-closure glaucoma as diphenhydramine's anticholinergic effects can precipitate this vision-threatening emergency 4, 5, 7
• Recognize that normal visual acuity does not exclude serious pathology; ocular-motor dysfunction and early orbital/intracranial lesions may present with subjective visual symptoms before measurable acuity loss 1