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. Conclusion: This is the first reported case of orbital cholesterol granuloma presenting with gaze-evoked amaurosis. Although these lesions usually cause progressive proptosis, they may rarely produce transient, gaze-dependent visual symptoms due to localized compressive effects. Complete surgical excision via an eyelid crease approach results in excellent outcomes with minimal recurrence risk and should be considered the treatment of choice.