To report a rare case with acute subperiosteal orbital hemorrhage following arteriovenous fistula repair

Subperiosteal orbital hemorrhage usually occurs in the setting of facial or orbital trauma. Non-traumatic cases have rarely been reported in literature and several theories of pathogenesis, including sudden elevation of cranial venous pressure, have been proposed.

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Here we present a 37 year old right-handed female with a past medical history significant for type 1 diabetes, end-stage renal disease on intermittent hemodialysis complicated by recurrent thrombosis of arteriovenous fistula, peripheral arterial disease status post femoropopliteal bypass requiring anticoagulation with Eliquis, and hypertension who developed acute onset right eye pain that progressed to bilateral vision loss following an elective outpatient venoplasty procedure for a clotted right upper extremity AV fistula. She was found to have significant periorbital swelling and chemosis on initial evaluation. CT orbits revealed large heterogeneously hyperdense lesions in the superior aspect of the extraconal orbits and maxillary sinuses bilaterally with proptosis. MR venography was negative for cavernous sinus thrombosis. DVT ultrasound demonstrated an acute thrombus in the right internal jugular vein. Cultures obtained through nasal endoscopy did not show evidence of an acute sinus infection. She was deemed not to be a surgical candidate per ophthalmology and otolaryngology evaluations due to low likelihood of clinical improvement with hematoma evacuation. She was treated conservatively for ocular hypertension. Visual acuity remained poor with finger counting on the right eye and lack of consistent response to light on the left eye.

Acute presentation of non-traumatic orbital hematoma warrants a thorough investigation for underlying vascular abnormality, venous congestion, infection and coagulopathy. Given the temporal relationship with the AV fistula repair procedure, our case highlights the importance of consideration of venous pressure changes as a potential cause of acute subperiosteal orbital hemorrhage.