Cholesterol Granuloma of the Orbit Presenting with Gaze Amaurosis – A Case Report

Introduction

Cholesterol granuloma is a rare, benign, cystic lesion of the orbit, and fewer than 200 cases have been reported in the English-language literature. We report an unusual case of orbital cholesterol granuloma manifesting as acute-onset gaze-evoked amaurosis, an association not previously described. Case Presentation: A 39-year-old male presented with an acute, crescent-shaped scotoma in downgaze of the right eye, associated with a five-day history of mild right upper eyelid swelling. Visual acuity, ocular motility and the rest of his ocular examination was normal. Imaging revealed a 1.7 cm cystic expansile lesion of the right superotemporal orbital roof causing bone remodeling. The lesion was biopsied through a superolateral eyelid crease incision, revealing a friable yellow mass with dark fluid. Histopathology demonstrated cholesterol clefts surrounded by foamy histiocytes, multinucleated giant cells, and hemosiderin-laden macrophages, confirming diagnosis of cholesterol granuloma. Cultures were positive for Propionibacterium acnes and Staphylococcus species, for which the patient completed a short course of oral antibiotics. Postoperatively, visual symptoms resolved immediately, and no recurrence was observed over six months.