A 48-year-old woman presented with 3 days of worsening right orbital swelling, eye pain, blurry vision, and 3 months of bilateral photophobia. She also reported bilateral rhinorrhea, congestion, and right frontal and temporal headaches. Active medical issues included hypertension, very poorly controlled type 2 diabetes, hyperlipidemia, tobacco use, and asthma. Her brother and father both had a history of chronic orbital swelling. Vital signs were unremarkable, and examination of the right eye showed moderate chemosis, injected conjunctiva, and periorbital edema. Both eyes were proptotic, right worse than left. She had normal bilateral extraocular movements, pupillary light reflexes, and gross vision. Computed tomography with contrast revealed bilateral ethmoid and frontal sinus opacification and right worse than left orbital fat stranding (Figure 1A). Magnetic resonance imaging with contrast demonstrated both enlargement and enhancement of bilateral extraocular muscles, especially the right superior rectus (Figure 1B). Initially she was started on antibiotic therapy. Right nasal biopsy, right endoscopic sinus surgery, and right anterior superior orbital tissue biopsy were performed. Intraoperatively, the sinus mucosa demonstrated only edema and mild secretions, but there was no necrosis or purulence. Both orbital and nasal cultures grew methicillin-resistant Staphylococcus aureus. Orbital biopsy showed nodular lymphoplasmacytic infiltrates without evidence of fungal infection or necrosis (Figure 1C). Further workup revealed elevated erythrocyte sedimentation rate, C-reactive protein, total IgG, and IgG4 levels and normal white blood cell count, thyroid-stimulating hormone, angiotensin-converting enzyme, lysozyme, antinuclear antibody, and antineutrophil cytoplasmic antibody (ANCA) levels.