In this case report we present an unusual case of orbital cholesterol granuloma associated with compressive optic neuropathy and cranial nerve 6th palsy. Cholesterol granuloma results from a foreign body response to the presence of crystallized cholesterol. Cholesterol granuloma affecting the orbit are a rare presentation as they typically occur in the petrous apex of the temporal bone. Computerized tomography scan and magnetic resonance imaging are extremely valuable in the diagnosis of cholesterol granuloma as they have characteristic radiological features. The treatment of cholesterol granulomas is based on the presentation and the symptoms and may include active surveillance versus surgical drainage. 

Cholesterol granuloma (CG) is a slow-growing benign lesion which results from a foreign body giant cell reaction to the presence of cholesterol deposits as a result of breakdown of blood products [1]. It is more common in men and presents with gradual mass effect [2]. CG typically occurs in the middle ear, mastoid antrum and petrous apex. Less frequently it has been reported in the frontal bone, zygoma, and paranasal sinuses [2].
The exact pathophysiology of CG is not well understood. However, several mechanisms including trauma as well as ventilatory obstruction in the bony cavity resulting in a negative pressure and subsequent haemorrhage and cholesterol deposition has been proposed [2,3]. The alternative hypothesis is the exposed marrow theory where the hyperplastic mucosa invades the underlying bone resulting in bleeding and chronic inflammatory response as the blood is metabolized [4]. 
CG has characteristic appearance on imaging. CG appears as a well-marginated lesion, isodense within the brain, usually with evidence of bony erosion on the CT. CG have a high signal intensity on T1-weighted sequence of the MRI due to their cholesterol component and methemoglobin content [3,5,6]. On T2-weighted sequence of the MRI, CG demonstrate central high signal which does not attenuate on FLAIR sequence. Furthermore, they do not demonstrate fat suppression and have no enhancement post-gadolinium [3,5,6].
In this case report we describe an atypical presentation of CG associated with compressive optic neuropathy and cranial nerve 6th palsy.