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Common causes of orbital hemorrhage include trauma, surgery, vascular anomalies, tumors, and blood dyscrasias. Subperiorbital (subperiosteal) hemorrhage is less frequent. This entity has been reported rarely in healthy individuals after forceful Valsalva maneuver.1-3 We describe a 37-year-old man who suffered subperiorbital hemorrhage after an episode of migraine-associated emesis.
Report of a Case
A 37-year-old white man with a medical history remarkable only for migraine headaches was seen 2 days after a typical migraine episode that included nausea and emesis. Immediately following emesis, the patient noted diplopia, decreased visual acuity of the left eye, pain with eye movement, and fullness about the left orbit.
Best-corrected visual acuity was 20/20 OU. Confrontation visual fields and pupillary responses were normal. Pain occurred with versions in all directions. Trace limitation of left supraduction and 6 prism diopters (PD) of right hypertropia were observed. Mild left upper eyelid edema and ecchymosis were present (Figure 1). Palpebral fissure heights and marginal reflex distances were 10 and 4 mm in the right eye and 8 and 3 mm in the left eye. Ballotment of the globes revealed increased resistance to retropulsion on the left and exophthalmometry measurements were 16 and 17 mm. Slitlamp biomicroscopy, tonometry, and funduscopy results were unremarkable.
External examination is remarkable for mild edema and trace ecchymosis of the left upper eyelid.
Magnetic resonance imaging after gadolinium enhancement identified a 10×15-mm mass along the medial aspect of the left orbital roof contained within an enhanced, elevated rim of periorbit (Figure 2). Intramass signal characteristics were most consistent with hematoma. Blood indexes and clotting parameters were normal.
Coronal T1 magnetic resonance imaging with fat suppression and gadolinium enhancement shows the enhanced, elevated rim of periorbit (large arrow). Note the acute angles of the osseous-periorbital junction demarcating the hematoma (small arrows).
Management was limited to observation. The diplopia and pain resolved, and the patient was without complaint 3 weeks later. Alternate cover testing revealed 2 PDs of asymptomatic right hyperphoria. Exophthalmometry results were unchanged.
Acute subperiorbital hemorrhage following Valsalva maneuver in otherwise healthy individuals has, to our knowledge, been reported 3 times. The first case occurred after emesis in a 9-year-old child with influenza.1 A second case resulted while a 23-year-old man lifted weights.2 The third case afflicted a 20-year-old pregnant woman during labor.3
All 4 patients had with orbital pain or fullness, normal or slightly decreased visual acuity, supraduction deficit, vertical diplopia, and axial proptosis. Each patient had normal intraocular pressures and pupillary responses. Interestingly, all were affected in the left orbit. In each case, radiography and/or echography demonstrated a superior subperiorbital hematoma. Three cases were observed and experienced complete resolution of symptoms by 1 month. Surgical exploration revealed an organized blood clot in the fourth patient.
Straining associated with the Valsalva maneuver increases intra-abdominal and intrathoracic pressures. The resultant increase in jugular venous pressure is transmitted to the orbit by valveless veins.2,3 Rupture of a bridging subperiorbital vessel presumably results in subperiorbital hemorrhage.2
In patients with a medical history and clinical examination suggestive of Valsalva-induced subperiorbital hemorrhage, we recommend computed tomography for confirmation. Magnetic resonance imaging, which was obtained in this case prior to referral, may also be used but is less cost-effective. Alternatively, the diagnosis can be secured by echography in the hands of an experienced clinician. We recommend observation as the initial management in patients without elevated intraocular pressure or optic neuropathy.
This study was supported by an unrestricted grant from Research to Prevent Blindness Inc, New York, NY, and the Wisconsin Lions Foundation, Rosholt. Additional support was provided by the Veterans Administration Hospital, Madison. Dr Lucarelli is a 1996-1997 Heed Ophthalmic Fellow.
Corresponding author: Matthew M. Boyer, MD, Department of Ophthalmology and Visual Sciences, University of Wisconsin Medical School, 600 Highland Ave, Dept F4/3, Madison, WI 53792-3220.
Boyer MM, Lucarelli MJ. Valsalva-Induced Subperiorbital Hemorrhage During Migraine. Arch Ophthalmol. 1998;116(1):117–118. doi:
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