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A 73-year-old man presented after a blunt left-sided orbital injury by a screwdriver. He had been seen at an emergency department 3 days previously but was unable to open his eye owing to tense eyelid oedema, and was discharged to follow-up with ophthalmology. He feels the swelling is improving and can now open his left eye (figure 1). Visual acuity is light perception only, he has restriction of extraocular movements and a left relative afferent pupillary defect, and the globe looks proptosed and feels hard on palpation. The right eye is normal with a Snellen visual acuity of 20/20.
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