Spontaneous Retrobulbar Hematoma During a Hypertensive Crisis Managed Without Surgical Decompression: A Case Report.

Spontaneous retrobulbar hematoma is an uncommon cause of acute painful proptosis and may rapidly threaten vision through orbital compartment syndrome. We report a 55-year-old woman with severe uncontrolled hypertension who presented with sudden painful right proptosis, profound visual loss, marked ocular tension, and restricted ocular motility. Computed tomography demonstrated a 16 × 20 mm right intraconal retrobulbar hematoma, while magnetic resonance angiography excluded a major underlying vascular abnormality. Urgent orbital decompression was planned. During preoperative preparation, the patient received intravenous methylprednisolone and antihypertensive therapy. Shortly thereafter, visual acuity recovered to 10/10 (20/20), intraocular pressure decreased to 18 mmHg, proptosis regressed, and ocular motility normalized. Because this improvement was rapid and sustained, decompression was deferred under strict ophthalmic monitoring with immediate surgical capability available if deterioration occurred. Follow-up imaging demonstrated progressive hematoma regression and complete radiological resolution at four weeks, without residual visual deficit. Medical therapy may have contributed to the improvement, although the relative contribution of each component of treatment cannot be determined from this single case. This case emphasizes repeated objective reassessment while maintaining urgent decompression as the standard approach when visual compromise persists or progresses.