Oscar Pistorius was sick in to a bucket for a second time in court, as he gazed upon an image of Reeva Steenkamp taken after he gunned her down in a hail of bullets.
The image had not been intended for display in the court at that time and Pistorius struggled to take it in - burying his head in his hands and then throwing up.
Earlier this week, Pistorius vomited repeatedly while listening to testimony by pathologist Prof Gerd Staaymen. He told the court Pistorius used shells designed to cause maximum carnage when striking human tissue, which killed Steenkamp.
The Olympic and Paralympic star had appeared calm and composed in the dock at North Gauteng High Court beforehand.
Seeing graphic images of the death scene was also too much for some of Steenkamp's friends present in court on day nine of the murder trial. Desi Myers bowed her head and looked like she was crying when the gory images were shown. Gina Myers fled the courtroom in tears.
The trial heard Pistorius covered Steenkamp in towels and plastic bags in a bid to stop the bleeding, after the 29-year-old was hit three times by so-called "dum dum" bullets.
Col Van Rensburg said he came across Pistorius downstairs in the kitchen but could not get any answer from the track star. Rensburg told the court he followed a trail of blood upstairs.
The Olympian and Paralympian denies murdering girlfriend Steenkamp. He claims he thought she was an intruder in his luxury home on the outskirts of Pretoria.
The prosecution claims he shot her dead following a row between the couple, however.
Pistorius also faces firearms charges.
The trial continues.