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.
Corresponding Author: Alexis Mathieu, MD, CHU Bordeaux, Service d’Ophtalmologie, Place Amélie Raba-Léon, 33076 Bordeaux Cedex, France (firstname.lastname@example.org).
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.
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