Primary Spontaneous Orbital Hemorrhage with Secondary Orbital Roof Blow-Out Fracture: A Case Report

Background and Clinical Significance: Periorbital ecchymosis, or "raccoon eyes," often indicates a basilar skull fracture. When trauma is absent, clinicians should consider other causes, such as Valsalva maneuvers, bleeding disorders, or systemic inflammation. Spontaneous orbital hemorrhage is rare, and its appearance as a mass causing a secondary orbital roof blow-out fracture is even more unusual. This report presents a unique case of primary spontaneous orbital hemorrhage (PSOH) leading to a secondary orbital blow-out fracture; Case Presentation: A 60-year-old man with a history of ulcerative colitis (UC) presented with acute-onset, non-traumatic, and bilateral periorbital bruising, swelling, and right-sided vision loss. Computed tomography (CT) showed a mass lesion in the right orbit with an associated orbital roof fracture. Following excision, histological examination showed extravasated blood. Additional laboratory work-up helped rule out possible hematologic and inflammatory etiologies, confirming a diagnosis of PSOH with a secondary orbital roof fracture; Conclusions: This case demonstrates that PSOH can generate sufficient intra-orbital pressure (IOP) to cause a secondary blow-out fracture, a phenomenon not previously reported in the literature. Furthermore, it emphasizes the need for a systematic diagnostic approach to exclude potential systemic etiologies in patients presenting with spontaneous periorbital ecchymosis. In addition, this case highlights the critical importance of rapid decompression in managing orbital compartment syndrome (OCS) to prevent permanent visual loss.