Teenager presents with unilateral proptosis

The Ophthalmology service was consulted to evaluate a 14-year-old girl in the emergency department with unilateral proptosis. For 3 months she was symptomatic with progressive right-sided nasal congestion, and in the 2 weeks before presentation, she noted right eye tearing. She became concerned when she noticed her right eye “bulging,” and her parents brought her to the emergency department. She reported mild, vague changes in her vision as well as intermittent tearing, but she denied blurry vision, double vision, color desaturation, eye pain or pain with eye movements.She was a healthy girl with a normal birth history, her vaccinations were up to date, and she had no significant medical or ocular history. She had no allergies and did not take any medications. Her family history included type 2 diabetes and hypertension. She was otherwise in her usual state of good health, and her review of systems was negative for fevers, night sweats, weight loss, nosebleeds and headaches. She had a pet bird, had not traveled recently, denied using nasal sprays, neti pots and humidifiers, and denied alcohol, tobacco and illicit drug use.