Spontaneous orbital haemorrhage in a healthy young male

Dear Editor, Orbital haemorrhage usually occurs as a result of trauma or surgery of the orbit. It has been reported as an uncommon complication of intraorbital vascular anomalies such as arteriovenous malformation or lymphangiomas, idiopathic orbital inflammation, and blood dyscrasias [1]. Rarely, it has occurred due to barotraumas while scuba diving [2]. Spontaneous orbital haemorrhage without any referable cause, however, is extremely uncommon [3]. Variable prognoses have been reported in the literature, from complete recovery with conservative management to severe cases with poor visual outcome despite emergency surgical intervention [4]. We report a case of spontaneous orbital haemorrhage in a healthy young male who was alternatively treated with systemic corticosteroids. A 25-year-old healthy young male awoke with proptosis, haemorrhagic chemosis and ecchymosis of the upper and lower lids of the left eye (Fig.1a,b). He had had an episode of migraine attack with vomiting of mild severity 1 day previously. There was no history of trauma, blood dyscrasias, or use of medications. On examination, his visual acuity was 20/20, OD and 20/40, OS. There was left proptosis of 5 mm by Hertel measurements, which remained stable upon performing the Valsalva maneuver. His intraocular pressure by Goldmann applanation tonometry was 11 mmHg, OD and 21 mmHg, OS, while fundoscopy was normal. There was limitation of eye movement in all directions. A relative afferent pupillary defect was weakly positive in the left eye. Bruit or thrill over the orbit was negative. Colour vision as tested by the Ishihara plates was normal. Computerized tomography angiogram of the orbit and brain revealed an intraconal haematoma measuring 2.86 × 1.4 × 2.23 cm lying superior to the left lateral rectus muscle, displacing the optic nerve medially (Fig. 1c,d). There was no evidence of abnormal vascular lesions in the brain or orbit. Screening for bleeding disorders, which included platelet count, bleeding time, PT, and PTT, was normal. Treatment options including lateral canthotomy were discussed, but the patient denied any surgical intervention. Having informed the risks and benefits of corticosteroids, we decided to start treatment with oral prednisone 1 MKD tapered over 3 weeks. Daily improvement of proptosis and eye movement was noted, and visual acuity returned to 20/20 in 3 weeks with no evidence of rebleeding at 4 months. Orbital haemorrhage usually occurs as a result of trauma [4]. Patients with spontaneous orbital haemorrhage usually have an underlying cause or predisposing factor to which the haemorrhage could be attributed, most commonly arteriovenous malformations and lymphangioma in young patients [3, 5]. Computerized tomography angiogram (CTA) and magnetic resonance angiogram (MRA) are imaging modalities that can help detect these vascular anomalies. Colour Doppler imaging is another convenient diagnostic modality, which is quick and comfortable for the patient but was unfortunately unavailable at the time. Our patient had no significant predisposing factor other than vomiting, and no clear etiology was identified from systemic workup and CTA of the brain and orbit. Though the patient had volunteered that the degree of vomiting was only mild and occurred only once, we cannot conclude that this did not cause breakage of the orbital vessels. Treatment with high-dose oral corticosteroids yielded good results without need for further surgical treatment. The authors have full control of all primary data, and agree to allow Graefe’s Archive for Clinical and Experimental Ophthalmology to review all data upon request. D. Wiwatwongwana :A. Wiwatwongwana (*) Department of Ophthalmology, Chiang Mai University, 110 Inthawarorot Street, Amphur Muang, Chiang Mai, Thailand 50200 e-mail: atchareeyaj@yahoo.com Graefes Arch Clin Exp Ophthalmol (2012) 250:1557–1558 DOI 10.1007/s00417-011-1747-0