58-year-old woman with multiple intracranial aneurysms complicated by subarachnoid hemorrhage due to rupture of an anterior communicating (A-comm) artery aneurysm status post (s/p) partial coil embolization underwent A-comm and left pericallosal aneurysm stenting at an outside hospital. She had been on aspirin for years and clopidogrel was started one week pre-procedure. She received heparin during, but not after, the procedure (total dose unknown). Several hours post-procedurally, she complained of sudden bilateral eye pain and vision loss. Imaging demonstrated bilateral subperiosteal orbital hematomas. Bilateral canthotomies were performed for orbital compartment syndrome, but the pain and vision loss persisted. She was emergently transferred for ophthalmology evaluation and collaborative management with neurocritical care and neurointerventional radiology.

Upon examination, her visual acuity was 20/40 in the left eye and no light perception in the right with a fixed and dilated pupil. Her globes were proptotic, and extraocular movements were significantly reduced bilaterally, but worse on the right. Intraocular pressure in the right and left eyes were 54 and 20 mmHg, respectively. After additional cantholysis on the right, intraocular pressure improved to 16 mmHg. She was subsequently started on brimonidine eye drops.

CT angiography did not reveal a bleed source. Aspirin was continued and P2Y12 was monitored closely while evaluating for clinical signs of further bleeding. Plavix was then restarted to maintain stent patency. She remained blind in the right eye with 20/25 vision in the left eye two weeks later.