An Unusual Case of Bilateral Subperiosteal Orbital Hemorrhage

Abstract

Subperiosteal orbital hemorrhage usually occurs in the setting of facial or orbital trauma. Non-traumatic subperiosteal orbital hemorrhage (NTSOH) has rarely been reported in literature. The proposed mechanism of NTSOH is the transmission of sudden increase in cranial venous pressure to the orbital veins, which are valveless. We present a case of a 37 year old right-handed woman with a past medical history significant for type 1 diabetes, end-stage renal disease, peripheral artery disease and hypertension who developed NTSOH following an elective revision of a clotted right upper extremity arteriovenous fistula. During this procedure, she had acute eye pain, bilateral complete vision loss and emesis. CT of the orbits revealed large heterogeneously hyperdense lesions in the bilateral orbital apex extending anteriorly along the roof of the orbit, concerning for hemorrhage. Cultures obtained through nasal endoscopy were negative for a bacterial or fungal infection involving the sinuses. Ophthalmology was consulted and she underwent bilateral canthotomy and lateral cantholysis. Postoperatively, she was started on systemic and topical ocular antihypertensives, as well as prophylactic antibiotics. Visual acuity remained poor with finger counting on the right eye and lack of consistent response to light on the left eye. This case highlights periprocedural increase in systemic venous pressure secondary to a fistula repair procedure as a potential cause of NTSOH.

Keywords: cranial nerve diseases; neurocritical care; neurohospitalist; neuroophthalmology; ophthalmoplegia.

Figure 1.

(A) Coronal and (B) Axial CT of the brain and orbits show the well-demarcated bilateral biconvex hemorrhages (red arrows) in the superior orbit. The medial aspect of the lesions run along the superior rectus muscles. (C) T1-weighted axial magnetic resonance imaging (MRI) of the orbits demonstrate biconvex lesions of mixed hyper/isointensity (red arrows) in the orbital roof bilaterally, representing NTSOH. (D) T2-weighted axial MRI of the orbits shows low signal lesions (red arrows), which along with the T1 sequence findings, reflect acute to early subacute hemorrhages.