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SUMMARY A 57-year-old housewife, with controlled hypertension, presented with acute right proptosis and visual loss with external ophthalmoplegia due to spontaneous orbital haemorrhage. Vision and ocular motility were returned to normal by the rapid surgical evacuation of the blood. Acute orbital haemorrhage is an ocular emergency requiring urgent treatment to prevent the usual previously reported outcome of permanent visual loss.Spontaneous orbital haemorrhage is the uncommon condition of haemorrhage within the orbit not caused by local trauma and not referable, so far as can be ascertained, to any constitutional causative condition. ' The visual prognosis is excellent except in the elderly, who often suffer permanent visual loss associated with a secondary vascular occlusion or an arterial bleed.2This case is reported as a reminder that rapid diagnosis of the cause of the visual loss and urgent surgical drainage of the blood are required to prevent irreversible visual loss. Case reportA 57-year-old housewife was awakened by severe right orbital pain associated with proptosis of the right eye and with ptosis, followed by nausea and vomiting. For the previous 18 months she had required Visken (pindolol) 5 mg twice daily for control of hypertension, Brufen (ibuprofen) 400 mg three times daily for arthritis, and Serepax (oxazepam) 30 mg each morning for 'nerves.' She had previously undergone the uneventful repair of an hiatus hernia, hysterectomy, stripping of varicose veins, and biopsy of a benign breast lump.Six hours after the onset of symptoms she was acutely distressed, with severe right orbital pain and vomiting. Her vital signs were normal, with a blood pressure of 110/70 mmHg. The corrected visual acuities were right 6/12, left 6/6. There was a complete right ptosis, ecchymosis of the eyelids, conjunctival chemosis, and irreducible right proptosis of 15 mm compared with the left eye by Hertel measurements. There was neither pulsation nor thrill nor bruit over the globe or orbit. The pupils were equal and reactive, and there was an almost complete external ophthalmoplegia of the right eye with residual abduction and elevation of only 50 (Fig. 1). Corneal sensation and all branches of the fifth cranial nerve were intact. Intraocular pressures by Goldmann applanation tonometry were right 48 mmHg, left 18 mmHg. Fundal examination was normal; there was neither papilloedema nor striae.She was admitted to the Royal Victorian Eye and Ear Hospital, where she received Diamox (acetazolamide) 500 mg intravenously. Urgent skull x-ray and computerized tomography were performed.Computerized tomography (Fig. 2) showed a large, dense (CT number 83), well rounded lesion in the right orbit extending from the lateral wall, displacing the globe forwards and downwards and flattening the posterior margin of the globe. The optic nerve was displaced medially. More posteriorly the lesion almost completely filled the whole of the posterior part of the orbit. The changes were consistent with acute haemorrhage into the right orbit.In...

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