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Melanoma

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

JAMA Ophthalmology

Published Online: August 11, 2022

JAMA Ophthalmology Clinical Challenge

Article Information and Disclosures

Alexis Mathieu, MD¹;

Romain Nicot, MD, PhD²;

Matthias Schlund, MD, MSc³

Author Affiliations

¹CHU Bordeaux, Service d’Ophtalmologie, Bordeaux, France
²University Lille, CHU Lille, Inserm, Service de Chirurgie Maxillo-Faciale et Stomatologie, U1008–Controlled Drug Delivery Systems and Biomaterial, Lille, France
³University Bordeaux, CHU Bordeaux, Inserm, Service de Chirurgie Maxillo-Faciale et Stomatologie, U1026–Bioengineering of Tissues, Bordeaux, France

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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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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

McCallum E , Keren S , Lapira M , Norris JH . Orbital compartment syndrome. Clin Ophthalmol. 2019;13:2189-2194. doi:10.2147/OPTH.S180058 PubMed Google Scholar Crossref

Kwon JH , Song YJ , Choi SS , Kim KU . Spontaneous intraorbital hemorrhage. J Korean Neurosurg Soc. 2008;44(3):156-158. doi:10.3340/jkns.2008.44.3.156 PubMed Google Scholar Crossref

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_21 PubMed Google Scholar Crossref

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.2015.11.009 PubMed Google Scholar Crossref

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.2020.4955 PubMed Google Scholar Crossref

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_18 PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.