Orbital Arterial Venous Fistula

An 82 year old male presented with a five week history of gradually worsening right upper and lower lid swelling and erythema, diplopia, and a dull ache OD. On examination visual acuity was 20/30 OU. He had three millimeters of protosis OD with poor retropulsion of the globe. A soft bruit could be heard over the right orbit. Motility exam revealed a small right hypertropia and exotropia with limited ductions in all fields of gaze. Slit lamp examination showed prominent engorged episcleral and conjunctival vessels, a clear anterior chamber and a normal iris without rubeosis. The intraocular pressure was mildly elevated (24 mm Hg) and th'ere was some tortuosity of the retinal vessels.