Microsurgical obliteration of a high-flow intraorbital arteriovenous malformation fed by the ophthalmic artery: Illustrative case

Background: Intraorbital arteriovenous malformations (AVMs) are exceedingly rare high-flow vascular lesions that pose a direct threat to visual function through progressive proptosis, optic nerve compression, and retinal ischemia. When the ophthalmic artery (OA) constitutes one of the arterial feeders, endovascular embolization carries a prohibitive risk of permanent visual loss, making microsurgical resection the treatment of choice. Case Description: An 18-year-old female presented with progressive right-eye proptosis, complete ophthalmoplegia, and reduced visual acuity of 20/70. Multimodal imaging confirmed an intraconal AVM supplied predominantly by the OA. Given the unacceptable risk of retinal ischemia associated with OA embolization, the patient underwent microsurgical resection through a fronto-orbital craniotomy. Stepwise feeder-by-feeder devascularization achieved complete lesion obliteration with significant visual recovery and an excellent cosmetic outcome. Conclusion: Microsurgical resection is the definitive treatment for intraorbital AVMs when the OA is the dominant feeder and endovascular intervention is contraindicated. Operative success depends on adequate cranio-orbital exposure, disciplined feeder-by-feeder devascularization, and meticulous preservation of retinal perfusion throughout. Classification of the lesion according to the International Society for the Study of Vascular Anomalies framework guides triage and informs the risk-benefit analysis of each therapeutic modality.