Spontaneous periocular ecchymosis as an unusual presentation of trochleitis

Figure 1.

A 67-year-old lady with psoriasis, presented with 2-days history of sudden-onset, sharp pain in the periocular area, worsening on eye movements and associated with bruising in the right upper eyelid. There was no history of trauma. Examination revealed focal ecchymosis and marked tenderness localized to superomedial aspect of the right eyelid (Figure 1A). Ocular motility was slightly limited in levoelevation, with associated diplopia. Visual acuity was 20/20 with unremarkable ocular examination. Contrast-enhanced magnetic resonance imaging demonstrated hypointensity and thickening of right superior oblique (SO) tendon-trochlea complex on T1-weighted (T1W) sequence (Figure 1B), which enhanced on fat-suppressed T1W postcontrast. (Figure 1C). A provisional diagnosis of trochleitis was established, for which intralesional triamcinolone acetonide was injected into the superomedial quadrant. At 3-weeks, complete resolution of ecchymosis, pain, and diplopia was noted (Figure 1D).

Spontaneous ecchymosis in trochleitis is a novel finding, which has not yet been reported. 1

Localised perivascular inflammation, exacerbated by concurrent psoriasis, may have resulted in extravasation of erythrocytes, a process potentially facilitated by the anatomically confined trochlear space and dense fibroconnective tissue, manifesting as ecchymosis. ²