A 34-year-old woman, 18 weeks pregnant, attended the emergency department because during an episode of hyperemesis gravidarum with projectile vomiting she suddenly presented with right supraorbital swelling with ocular proptosis and visual alterations of the right eye. The patient had no personal history of interest, was not taking any regular medication and had not previously suffered any trauma.
Ophthalmological examination revealed exophthalmos with hypophthalmos of the right eye, right mydriasis of 7 mm with decreased pupillary reactivity, limited supraduction and supraversion with diplopia, myodesopsia and painful upper eyelid oedema on palpation. Fundus examination was normal with intraocular pressure of 24 mmHg. No oedema or vascular abnormalities were observed in the conjunctiva.

As the patient was pregnant, an urgent orbital magnetic resonance imaging (MRI) scan was requested and the findings were compatible with a diagnosis of right extraconal intraorbital right intraorbital haematoma. A blood test based on routine haemogram, biochemistry and coagulation showed no abnormalities that could have precipitated the picture.
Given the clinical repercussions and the increasingly evident changes in the patient's vision, it was decided to perform urgent surgery to evacuate the haematoma and decompress the orbit under general anaesthesia. A right upper blepharoplasty approach was performed, dissecting the orbicularis oculi muscle and the periosteum, until reaching the orbital supero-external bony rim. When the periosteum was incised at the level of the orbital aspect of the frontal bone, blood and clots from the extraconal haematoma were released under pressure. After evacuation of the haematoma there were no bleeding spots from any vessels in the region. A fine Penrose drain was placed and treatment for hyperemesis gravidarum was started with pyridoxine 10 mg/8 h iv + thiamine 100 mg/24 h iv + metoclopramide 10 mg/8 h iv.

The patient evolved favourably after surgery, with mydriasis and visual alterations disappearing in the first postoperative hours, and the drainage was removed after 48 h. Currently, 3 months after surgery, the patient is asymptomatic and without sequelae.