Promote early identification and possible intervention in rare causes of peri-orbital edema such as ethmoidal-orbital arteriovenous fistulas and thus, prevent grievous complications.

51-year-old male with past medical history of diabetes, Hepatits B (on Tenofovir), was referred to the ED for right eye periorbital edema for 1 week with no improvement with Augmentin for presumed orbital cellulitis. Periorbital swelling was painful, progressive with impaired visual acuity (Right 20/40 and Left 20/25), pain with extra ocular movement and global diffuse headache. Intraocular pressure in right eye was 10, 12 in left eye. Not associated with trauma, fever, focal neurological deficits.
CT head, MRI brain and orbits, along with MRA head wit gadolinium revealed changes concerning for dural AV fistula. 

A cerebral angiogram confirmed bilateral ethmoidal-ophthalmic artery arteriovenous malformation draining into retro-orbital cerebral vein with reflux into the sylvian vein and the cavernous sinus.