Intermittent Bilateral Exophthalmos (Alternating Exophthalmos and Enophthalmos) on Physical Exam Observing this patient in silence for a few mins resulted in a very interesting finding which was not apparent initially. This condition can be vision- or life-threatening. Proptosis significantly increased with expiration and Valsalva maneuvers. No orbital bruit on auscultation. CT head showed engorgement of the superior and inferior ophthalmic veins CT angiogram confirmed the dilated ophthalmic veins with ~ 1.5 - 2 cm right retroorbital venous varix. Patient underwent a diagnostic angiogram, and embolization of right carotid cavernous fistula was performed successfully therefore reducing this condition. Treatments are aimed at preserving vision, salvaging the globe, preventing disfigurement, and reducing mortality. Existing case reports usually describe a unilateral presentation with left eye predominance. In this patient- bilateral symptoms which is usually not seen in any available case reports. There was also right eye predominance which is less common. The syndrome of intermittent exophthalmos consists of proptosis that occurs rapidly whenever the head is lowered or when venous pressure is temporarily increased. The cause of this unusual form of exophthalmos is a venous abnormality behind or above the globe. Differentials for this are: Infectious, inflammatory, vascular, and neoplastic entities that range from benign and indolent, to malignant and aggressive. Commonly, vascular malformations within the orbit, arteriovenous aneurysms, hemangiomas, and lymphangiomas are the cause. #Exophthalmos #Enophthalmos #Alternating #Bilateral #clinical #video #ophthalmology #physicalexam #Respiratory #Variation #proptosis
