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Dural arteriovenous fistulas (dAVFs) involving the optic nerve sheath are rare and often present subtly. We report a case of a woman in her 50s with a month-long history of left eye redness, swelling and watering. Examination revealed proptosis and chemosis without vision loss or cranial nerve deficits. MRI showed a dilated superior ophthalmic vein (SOV), initially suggesting a carotico-cavernous fistula. However, digital subtraction angiography confirmed a slow-flow intraorbital dAVF supplied by the left ophthalmic and accessory meningeal arteries, draining via the SOV. Conservative management with carotid compression failed, and after 1 year, worsening symptoms and thrombosed venous outflow precluded standard endovascular access. A direct ultrasound-guided SOV puncture was performed using a micropuncture needle. Embolisation with detachable coils and Menox 18 achieved complete fistula occlusion, with clinical improvement. This case highlights the role of catheter angiography in diagnosing intraorbital dAVFs and demonstrates the feasibility of direct SOV puncture when conventional routes are inaccessible.