The patient came to the clinic 10-July-2011 complaining of exophthalmus left eye 1 month with feeling of heaviness of the eye.

MRI brain and orbits done 10-July-2011 showing retrobulbar mass below the globe of the left eye, pushing the optic nerve up and the globe anterior.

On examination: the patient has weak left upper and lower limbs with hypalgesia below C3, for what MRI cervical MRI was requested and done 16-July-2011 which was normal. There was slight changes in the visual fields of the left eye. The oculomotor nerves and movements were normal. Upon palpation of the left eye, it was possible to palpate the mass under the globe when the patient flexing the head down, but when he look up the mass disappear.

Lateral canthotomy for the left eye was done. The incision was extended 20 mm laterally. Osteotomy of the lateral wall of the orbit was done, so that the lower edge is flush with the inferior margin of the orbit. The periorbita was opened below the lateral rectus muscle projection. The mass was explored and it was a cluster of venous walls with capillary feeders coming from all the surrounding structures. The hemangioma was coagulated stepwise and sharp dissection was necessary to prevent trauma to the globe and lateral rectus muscle. Fresh frozen biopsy was done confirming the hemangioma. The vascular mass was followed all over and dissected off the optic nerve and the inferior rectus muscle. It was followed, so the the dissection was carried out until the medial wall of the orbit was identified. Practical total resection was achieved. Inspection of the optic nerve and all the surrounding anatomical structures were carried out to rule out presence of any remnants.

Routine closure of the wound.  Smooth postoperative recovery with preservation of vision left eye.

Exophthalmus is the fist sign of benign intraorbital masses.

The disappearance of the mass when the face up and exaggeration when looking down make the vascular malformation more favorable.

The lateral approach is the most superior approach in such case, since the surgeon can bring under visual control 3-4 of the anatomical structures.