Pulsatile Exophthalmos Due to Inadequate Orbital Reconstruction Following Fronto-Orbito-Ethmoidal Fibrous Dysplasia Resection

Pulsatile exophthalmos can be a presenting sign of several orbital pathologies, such as trauma, iatrogenic injury, or congenital defect, or as a complication after orbital reconstructive surgery. Traditional approaches to management are conservative, with the goal being spontaneous resolution. The following case illustrates this rare but clinically significant complication and its treatment strategies. A 48-year-old male underwent a bifrontal craniotomy with resection of a fibrous dysplasia, followed by reconstruction of the skull base and orbit with split-thickness calvarial autograft. Prior to leaving the operating room, the patient's eye was pulsating, and the diagnosis of pulsatile exophthalmos was made. A discussion with the patient's family resulted in the joint decision to undergo additional split-thickness calvarial bone grafting to further repair the lateral orbital wall. Postoperatively, the patient exhibited no further vision loss without evidence of CSF leak or additional complications. This report presents a case of iatrogenic pulsatile exophthalmos with complete resolution of symptoms after additional reconstructive measures. This case serves to highlight the importance of the ocular examination prior to completion of cranial cases involving orbital reconstruction. Increased surveillance and timely correction of this finding may reduce the risk of disabling ocular symptoms.