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Show Journal of Neuro- Ophthalmology 17( 4): 266, 1997. © 1997 Lippincott- Raven Publishers, Philadelphia Images Trivial Trauma An 18- year- old college student was studying for finals in his dormitory room late one evening when he dropped his pencil onto the ground. While bending over to pick it up, he struck his right mesial brow against a desk. There was no apparent injury to his skin and he did not develop ecchymosis. Within minutes he noted the onset of vertical diplopia associated with a right frontal headache. He was seen the next day by his physician, who then referred him for consultation. He had an unaided visual acuity of 20/ 15 in each eye and had no afferent pupillary defect. Findings on his slit lamp examinations were normal, as was the case with his dilated fundus examination. He exhibited an 8- mm right hypotropia associated with 10 prism diopters of right hypotropia in the primary position. He was orthophoric in down gaze and increased to 20 prism diopters in up-gaze. FIG. 1. A: Coronal MR scan at mid- i Gregory S. Kosmorsky, D. O. With a Twist A MR scan revealed the presence of a large subperiosteal hematoma superiorly in the right eye causing obvious downward displacement of the globe ( Fig. 1). Although several consultants recommended immediate evacuation of this hematoma, careful follow- up was chosen as the treatment of choice. Over several weeks the hypotropia and the diplopia began to abate, and by the sixth week after the injury he was totally without diplopia. This case is unusual in that seemingly minor trauma produced a large hematoma that caused a significant vertical deviation. It may be that a bridging vessel was trans-sected in the subperiosteal space because of the shearing forces created with the downward moving head against the desk. Although a surgical option could have been considered in this patient, watchful waiting produced the most desirable outcome of an asymptomatic patient in a short period of time. i. B: Coronal MR scan just posterior to globe. 266 |