Pediatric orbital compartment syndrome: A lymphatic malformation complication

Orbital compartment syndrome (OCS) is a vision-threatening emergency. In adult cases, most are caused by trauma. Pediatric OCS is rare and associated with non-traumatic etiologies. Pediatric OCS poses unique diagnostic and procedural challenges related to anatomy, intraocular pressure measurement, and sedation. A 15-year-old male presented to the pediatric emergency department (PED) with three days of progressive right eye pain, swelling, and blurry vision with similar milder episodes one year prior. Eye exam revealed decreased right vision (20/70), proptosis, and ophthalmoplegia. CT imaging demonstrated multiple right intra-orbital masses. The patient suddenly developed severe eye pain prompting OCS concerns with emergent lateral canthotomy. MRI demonstrated lymphatic malformation with complete optic nerve encasement, severe proptosis, and posterior scleral tenting. With definitive management (percutaneous drainage, steroids, and sirolimus), visual acuity improved with no optic nerve damage. This pediatric OCS case highlights the non-traumatic etiologies, particularly lymphatic malformations prone to spontaneous intralesional hemorrhage. For pediatric eye pain complaints, emergency physicians must maintain vigilance for OCS by recognizing worsening orbital signs and facilitating decisive intervention lateral canthotomy.