Orbital apex syndrome after trauma in a 6-year-old – a rare occurrence

Abstract

A 6-year-old boy was brought to the casualty department at Northdale Hospital, Pietermaritzburg, South Africa, after having fallen onto a tree stump while playing in a park. There was no history of loss of consciousness, vomiting or seizures after the fall. He was awake and orientated to person, place and time when he arrived at the hospital. On examination he was found to have swelling and abrasions on the middle of the forehead, the left cheek and the left upper eyelid. There were no eyelid lacerations. The pupils were equal and reactive. There was no documented hyphaema or chemosis of the eye, but there was conjunctivitis. There was no objective documentation or examination of the eye movements. A skull radiograph was done, and no fractures were noted. The final assessment of the patient by the casualty officer was blunt-force trauma with no vision loss, and he was discharged with analgesics and chloromycetin ointment.Nine days later the patient was brought to casualty again, complaining of headaches and pain originating from the left eye. There was also an unusual complaint of bleeding from the eye. According to the notes, his vital signs were documented as stable. On examination of the eye, there was chemosis but no hyphaema or conjunctivitis. All eye movements were documented as having a full range in all directions. The eyes were irrigated, and the patient was discharged again with chloromycetin ointment and analgesics. Of note, this was a different doctor from the first, and no further radiological investigations were done.Three days later the patient's mother brought him to Northdale Hospital for the third time, and he was finally referred to the eye clinic. In the eye clinic his visual acuity was assessed as 6/18 in the right eye and poor light perception in the left eye. The intraocular pressure (IOP) in the right eye was 22 mmHg and that the left eye 33 mmHg. There was a 4 mm proptosis of the left eye compared with the right eye, measured with an exophthalmometer. The findings on anterior segment examination of the right eye were normal. Examination of the fundus showed a normal pink disc with a 0.1 cup/disc ratio. The macula of both eyes was normal.Examination of the left eye showed the following: • There was complete ptosis of the left eyelid.• Proptosis was evident.• The conjunctiva was clear.• The cornea was clear.• The anterior chamber was deep and no cells or flare were noted.• The lens was clear, but the pupil was mid-dilated.• There was a reactive afferent pupillary defect.• The extraocular muscles showed no movement in all cardinal directions of the eye, and it was centrally fixed in the orbit.• Fundus examination showed a pink disc, a cup/disc ratio of 0.2, and no swelling of the optic disc.The patient was assessed as having complete ophthalmoplegia, ptosis and proptosis of the left eye. He was immediately referred to a tertiary hospital and an emergency computed tomography (CT) scan of the brain and orbits with contrast was booked for the same day. The scan revealed a left medial blow-out ...

A Meta-Analysis of Traumatic Orbital Apex Syndrome and the Effectiveness of Surgical and Clinical Treatments

“…Over the last 50 years, a total of 347 articles pertaining to OAS were found in the literature. Of these, only 22 pieces of literature met the inclusion criteria and remained for analysis 2–28,34 ( Fig. 2).…”

“…In this situation, a patient with facial trauma may present with TOAS, in the absence of any clear radiographic evidence of facial fractures trapping the cranial nerves, likely related to compression of these structures by swelling of the retro-bulbar soft tissue or a small hematoma. In practice, each case of TOAS likely has both direct and indirect mechanisms at play 2–25 . Traumatic orbital apex syndrome can result both from primary trauma and iatrogenic trauma as well 26–28 …”