Successful Treatment of the Traumatic Orbital Apex Syndrome due to Direct Bone Compression

Abstract

Traumatic orbital apex syndrome is a well-known but rare complication of craniomaxillofacial trauma that combines features of the superior orbital fissure syndrome with traumatic optic neuropathy. The optimal treatment of traumatic orbital apex syndrome has not been established, because there have been so few cases. We report a case of traumatic orbital apex syndrome combined with the blow-in type of the orbital and zygomaticomaxillary complex (ZMC) fracture, which was successfully treated by emergency decompression of impinged nerves, and had complete recovery of visual and ocular function. We also discuss the indications for and timing of surgical intervention for cases of direct traumatic orbital apex syndrome with facial fracture. CaseA 24-year-old male on a bicycle collided with a wall at the bottom of a hill due to brake failure. The main impact was sustained on the left side of his face. He was referred to our emergency center for urgent treatment of his facial injuries. On initial examination, two hours after his accident, the patient presented with a Glasgow Coma Scale score of 12.He had left periorbital ecchymosis, left lid ptosis, and decreased left visual acuity. He had only the ability to count fingers at 50 cm, compared with the ability of the nonaffected right eye to read figures without his glasses, which were lost at the trauma scene. The pupils were anisocoric: 5 mm on the left versus 3.5 mm on the right. Direct pupillary reflex was sluggish on the left eye and intact on the right. Indirect pupillary reflex of both eyes was maintained. He also had lost the left corneal reflex, and had paresthesias over the left frontal region, ocular motility disorder of the left eye in all directions of gaze, and elevated left ocular pressure on palpation (►Fig. 1). Opthalmologic evaluation performed in the emergency room was limited due to head trauma and generalized convulsion. The relative afferent pupillary defect (RAPD) was positive for the affected left eye but negative for the right eye. Although the lower eyelid was edematous, the optic media, such as the iris, lens, and vitreum was found intact. The left optic disc was found to be slightly erythematous.Computed tomography (CT) revealed a left sided orbital and ZMC fracture of the blow-in type, in which the inward displacement of the fractured segments results in decreased AbstractOrbital apex syndrome is an uncommon but severe ocular complication of craniomaxillofacial fracture. The optimal treatment strategy for this very rare traumatic syndrome has not been well established. We present a case in which traumatic orbital apex syndrome was caused by direct compression from the displaced fracture segments. Visual and extraocular function both improved quickly after emergency decompression surgery. This case suggests that managing the direct type of traumatic orbital apex syndrome with craniomaxillofacial fracture with a combination of urgent reduction of impinging bone and decompression of affected nerves is an effective strategy.

Examination of the Topographical Anatomy and Fetal Development of the Tendinous Annulus of Zinn for a Common Origin of the Extraocular Recti

“…[10][11][12] Third, ophthalmic veins appeared to avoid the thick common tendon when draining from the orbit. In radiologic evaluations of orbital apex syndrome, [13][14][15] it appears that no one has yet discriminated the tendon from the periosteum extending along the orbital fissure. Fourth, notably, in addition to this tendinous origin, we found that parts of the SR and/or LR fibers originated from the optic or oculomotor nerve sheath (Figs.…”

Functional Recovery of Cranial Nerves in Patients with Traumatic Orbital Apex Syndrome

“…Therefore, even minor craniofacial force might cause neurological disorders around the cranial apex region and thus lead to TOAS. According to degree of compression on imaging data, TOAS can be divided into two types: (1) direct damage resulting from fracture fragment, foreign bodies, or hematoma and (2) indirect damage resulting from secondary inflammation and edema [ 12 ]. It is widely acknowledged that hemorrhage inside the meningeal sheath, optic nerve swelling, and necrosis secondary to decreased blood flow could be the main pathology of TON.…”

“…On the contrary, Pletcher et al [ 17 ] proposed that simple steroid treatment might have worse prognosis compared with surgical decompression. Imaizumi et al [ 12 ] reported that one case receiving decompression of optic canal and SOF regained visual perception successfully. While in another study [ 10 ], 2 cases of TOAS underwent conservative treatment of steroid and vitamin B12 with one of them presenting no improvement and the other one presenting incomplete eye movement.…”

Successful delayed treatment of the traumatic orbital apex syndrome by nasal endoscopic decompression surgery

“…[ 1 ] This case illustrates all of the hallmarks of an OAS, which include visual loss from optic neuropathy, ophthalmoplegia resulting from multiple cranial nerves (oculomotor, trochlear, and abducens), and numbness in the territory of the ophthalmic branch of the trigeminal nerve. [ 1 2 ]…”