We report the case of a previously healthy 64 year old woman who was admitted with sudden onset headache and blurring of vision. Examination showed visual acuity of 6/9 on the right and 6/36 on the left. There was distinct periorbital bruising (figure A). Ocular movements were normal. The optic discs were swollen with engorged retinal vessels and scattered retinal haemorrhages (figure B). Brain CT showed diffuse subarachnoid haemorrhage with a possible anterior communicating artery aneurysm. This was confirmed on angiogram.

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Terson's syndrome1 (vitreous haemorrhage) and other ocular haemorrhages have been reported to occur in up to 40% of patients with ruptured aneurysms. Periorbital bruising has been described in association with basal skull fracture,2orbital cellulitis, and cavernous sinus thrombosis.3 To our knowledge it has never been described in subarachnoid haemorrhage secondary to aneurysmal rupture. We think that the bruising is probably due to venous stasis and rupture of small tributaries of the superior and inferior ophthalmic veins. This, in turn is probably due to decreased venous return to the cavernous sinus as a result of a sudden increase in intracranial pressure.