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A Recurrent Orbital Hemorrhage in an Older Adult

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A patient in their 70s presented to the emergency department (ED) with a unilateral painless right proptosis, first noticed 3 days prior. There was no contributory medical history, recent trauma, or surgery. Visual acuity (VA) was 20/32 OD and 20/20 OS. Anterior-segment and fundus examination results were normal. Magnetic resonance imaging (MRI) of the orbits revealed a right retro-orbital hemorrhage. No etiology could be identified on the image. Systemic corticosteroid therapy (methylprednisolone, 1 mg/kg per day) was prescribed for 48 hours. The proptosis decreased, and the patient was discharged.

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Recurrent retrobulbar hemorrhage owing to an orbital tumor: a primary orbital melanoma.

C. Additional imaging, including a computed tomography and positron emission tomography scan

The differential diagnosis of a retrobulbar hemorrhage includes orbital trauma; recent orbital, eyelid, lacrimal, or sinus surgery; orbital vascular anomalies; Valsalva-related hemorrhage in a patient with sinonasal carcinoma; and primary orbital tumor or metastasis.1,2 In this patient, there was no history of recent trauma or orbital or periorbital surgery. This presentation—recurrent retrobulbar hemorrhage associated with orbital mass effect over several weeks and restriction in upgaze—suggests an orbital tumor history but is not specific enough to eliminate an orbital vascular anomaly. At this stage, scheduling a follow-up without further investigation is not acceptable.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Corresponding Author: Alexis Mathieu, MD, CHU Bordeaux, Service d’Ophtalmologie, Place Amélie Raba-Léon, 33076 Bordeaux Cedex, France (a.mathieu47000@gmail.com).

Published Online: August 11, 2022. doi:10.1001/jamaophthalmol.2022.2875

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank Romain Perbet, MD, for the pathological analysis of this difficult case. There was no financial compensation for this contribution.

References
1.
McCallum  E , Keren  S , Lapira  M , Norris  JH .  Orbital compartment syndrome.   Clin Ophthalmol. 2019;13:2189-2194. doi:10.2147/OPTH.S180058PubMedGoogle ScholarCrossref
2.
Kwon  JH , Song  YJ , Choi  SS , Kim  KU .  Spontaneous intraorbital hemorrhage.   J Korean Neurosurg Soc. 2008;44(3):156-158. doi:10.3340/jkns.2008.44.3.156PubMedGoogle ScholarCrossref
3.
Nagesh  CP , Rao  R , Hiremath  SB , Honavar  SG .  Magnetic resonance imaging of the orbit, part 2.   Indian J Ophthalmol. 2021;69(10):2585-2616. doi:10.4103/ijo.IJO_904_21PubMedGoogle ScholarCrossref
4.
Ducasse  A , Merol  JC , Bonnet  F , Litré  F , Arndt  C , Larré  I .  [Adult orbital tumors].   J Fr Ophthalmol. 2016;39(4):387-399. doi:10.1016/j.jfo.2015.11.009PubMedGoogle ScholarCrossref
5.
Kalemaki  MS , Karantanas  AH , Exarchos  D ,  et al.  PET/CT and PET/MRI in ophthalmic oncology (Review).   Int J Oncol. 2020;56(2):417-429. doi:10.3892/ijo.2020.4955PubMedGoogle ScholarCrossref
6.
Allen  RC .  Orbital metastases: when to suspect? when to biopsy?   Middle East Afr J Ophthalmol. 2018;25(2):60-64. doi:10.4103/meajo.MEAJO_93_18PubMedGoogle ScholarCrossref
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