Sir,

Orbital cellulitis is an ophthalmic emergency that may lead to both life- and sight-threatening complications. We report the case of a child who presented with orbital cellulitis secondary to self-inflicted periocular and facial lacerations during sleep. He regained normal visual function after propitious ophthalmic and psychiatric intervention.

Case report

A 6-year-old boy presented with a 2-day history of painful protrusion of the left eye.

On examination, multiple fresh and old scratch marks were seen over his face. The left eye showed lacerated wounds on the lids, axial proptosis, ptosis, and conjunctival chemosis (Figure 1). Vision was 6/12. Extraocular movements were restricted. Pupils and retinal examination were normal. Computerized tomography scan showed diffuse inflammation of the left orbit. Paranasal sinuses and brain study were normal. Based on these findings the diagnosis of orbital cellulitis secondary to self-inflicted periocular injury was made.

Figure 1
figure 1

Clinical photographs showing (a) right lateral; (b) frontal; (c) left lateral views of the patient with facial scratch marks and left eye ptosis, proptosis, and periocular lacerations.

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Clinical improvement was noted after 48 h of intravenous antibiotics (Figure 2).1 Psychiatric evaluation revealed attention deficit/hyperactivity disorder (ADHD) with night terrors. The child was prescribed Methylphenidate and Clonazepam for his ADHD and parasomnia, respectively. He was advised to wear gloves during sleep.

Figure 2
figure 2

Clinical photograph after treatment.

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Currently, at 9 years of age, he is not using either medications or gloves. He has not had any episodes of self-injury for the past 2 years.

Comment

Parasomnias, defined as undesirable behavioral events during sleep, for example, nightmares, sleep terrors, and sleep walking, are common in the general population. Disorders of arousal, like sleep terrors, are the most common parasomnia seen in boys aged 5–7 years.2

The child may sit up, scream, and appear frightened, with increased pulse and respiratory rates and sweating. For most children, treatment is not necessary. Adhering to good sleep routines will usually reduce the frequency of events.3 If sleep terrors cause an injury, parents/guardians need to be educated about creating a safe environment for the child.4 The etiology of orbital cellulitis in the pediatric age group is varied, ethmoid sinusitis being the commonest.5 To our knowledge, this is the first reported case of orbital cellulitis secondary to self-inflicted trauma due to parasomnia in a child. However, in any case of trauma in a child, non-accidental injuries should be ruled out. In case of parasomnia, it is important to prevent further episodes by psychotherapy and protective measures.