Peeping Painless Proptosis.

DR. XIAO CHI ZHANG: A 92-year-old woman with dementia was brought to the emergency department (ED) from a nursing home for headache and “left eye bulge” after falling backward, striking her head on the ground. While the review of systems was limited due to the patient’s baseline dementia, she only reported occipital headache, left knee pain and denied any eye pain, changes in her vision and stated: “my right eye is my bad eye.” Her past medical history was significant for bilateral glaucoma, right orbital reconstruction due to childhood trauma, and coronary artery disease. Current medications included aspirin/extended-release dipyridamole (Aggrenox®), timolol, and latanoprost eye drops. On arrival to the ED, the patient’s blood pressure was 154/66 mm Hg, pulse rate 63 beats/min, respiratory rate 20 breaths/min, temperature 36.5°C (97.7°F), and SaO2 96% on room air. She was in no acute distress without any obvious signs of external trauma. She was alert and oriented to her name, perseverated on her headache, and had reproducible left knee discomfort with active range of motion. Her external ocular exam was significant for a left proptotic eye, with a 3mm pupil that was reactive to light and a normal appearing right eye with a surgical, 3mm pupil; there were no signs of irritation or hyphema on either eye (Figure 1). Her left extraocular motion (EOM) was intact, but her right eye movement was restricted on superior temporal, inferior temporal, superior nasal, and inferior nasal motions. She was able to see fingers through her left proptotic eye, but unable to perceive light on her right eye. The patient denied diplopia and there was no appreciable afferent pupillary defect. The remainder of her physical exam and trauma evaluation was negative for any major deformities, contusions, ecchymosis, hematomas, lacerations or step-offs. Initial blood work was unremarkable for acute metabolic or hematologic abnormalities. Imaging revealed a normal chest x-ray. A computed tomography (CT) scan of the brain, face, and neck revealed a soft-tissue mass within the left orbital space without any obvious evidence of acute infarct, hemorrhage, mass or mass effect in the brain or facial fractures (Figure 2). The differential diagnosis for this mass included a retrobulbar hematoma, given the patient’s history of trauma while on an antiplatelet agent.