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A. G. Alzaga Fernandez, J. Lee, M. Christianson; Minor Trauma, Major Bilateral Sub-Periosteal Orbital Hematomas. Invest. Ophthalmol. Vis. Sci. 2010;51(13):6313.
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To report a case of bilateral superior sub-periosteal orbital hematomas with compressive optic neuropathy after minor trauma with complete resolution after drainage.
A 31-year-old apparently healthy Caucasian woman presented three days after an episode of dizziness leading to a fall, complaining of progressive bilateral proptosis. She denied hitting her head and no physical evidence of ecchymosis or edema pointed to head injury. Exam revealed downward displacement of the globes, bilateral eyelid edema, decreased vision and ophthalmoplegia. Visual acuity at near was equivalent to 20/400 in both eyes. Pupils were equal and normally reactive to light with no afferent pupillary defect. Severe bilateral eyelid edema and conjunctival chemosis were present. Fundus exam was normal. A contrast CT scan of the orbits demonstrated bilateral superior orbital masses. Over the course of 12 hours, visual acuity deteriorated to count fingers at one foot in both eyes and the pupils became unresponsive to light. The patient underwent emergency bilateral transseptal anterior orbitotomies, with exploration and drainage of the sub-periosteal masses. Evacuation of blood clots resulted in decompression of the orbits. Her visual acuity, pupillary function, extraocular motility and color vision improved immediately after the procedure. At one-month follow-up examination, visual acuity had improved to 20/30 in both eyes, motility was full, and pupillary light reflexes and confrontation visual fields were normal. The eyelid edema and chemosis had resolved completely.
Reports of sub-periosteal orbital hematomas are rare in the ophthalmology and radiology literature. Bilateral cases are even less common. Most cases of sub-periosteal orbital hematoma occur in association with direct orbital trauma, endoscopic sinus surgery, coagulopathy, paranasal sinusitis or venous congestion. Our case is unique in that bilateral vision-threatening, sub-periosteal orbital hematomas occurred after apparently minor trauma with no external evidence of injury and no coagulopathy.
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