Orbital apex disorders: Imaging findings and management

Clinical anatomy of the spina musculi recti lateralis: A frequently overlooked variation of the greater wing of the sphenoid

BACKGROUND

The spina musculi recti lateralis (SMRL) is often visible along the lateral rim of the superior orbital fissure (SOF). Aim of this study is to characterize SMRL morphology and topography relative to known bony landmarks.

METHODS

Orbits from 291 adult dry skulls and from 60 CT scans were analyzed to measure the distance between the SMRL and the SOF or the inferior orbital fissures (IOF) as well as its height, width and orientation. Processes other than SMRLs were also recorded. Fetal skulls were observed for comparison with adult samples.

RESULTS

Forty-one per cent of orbits on dry skulls and 43.3% by CT showed an SMRL. Additional 32.9% of orbits on dry skulls had processes with a different shape. On average, SMRL were orientated almost along the transverse plane and showed implant bases as wide as 141.9° or as narrow as 36.8°. SMRLs were close to the infero-posterior angle of the orbital plate of the sphenoid, 1.21 ± 0.84 mm in front of the SOF, 5.8 ± 1.9 mm above the IOF and 12 ± 2.3 mm from the anterior end of the SOF. They were 1.58 ± 0.64 mm high and did not show any age or sex-related prevalence. By CT, the SMRL appeared as the insertion site for the lateral rectus, tendinous ring and, sometimes, inferior rectus.

CONCLUSIONS

The SMRL is a process of the sphenoidal orbital plate rather than of the SOF. It is also a reliable landmark for the insertion of the tendinous ring and lateral rectus. Orbital surgeons should be aware of this common variant of the orbital apex.

Sinonasal Orbital Apex Syndrome, Horner Syndrome and Pterygopalatine Fossa Infection: A Case Report and Mini-Review

This paper presents a literature review and a case of an 83-year-old otherwise healthy female patient with a history of recent syncope, a sudden-onset right-sided temporal headache, diplopia, and vision loss. An exam revealed right-sided upper eyelid ptosis, myosis, vision loss, ophthalmoplegia, and a positive relative afferent pupillary defect on the right eye. CT showed sphenoid sinus opacification, eroded lateral sinus wall, Vidian canal, disease extension to the posterior ethmoid air cells, orbital apex, medial orbital wall, and pterygopalatine fossa. An orbital apex syndrome (Jacod's syndrome), Horner syndrome, and pterygopalatine fossa infection were diagnosed due to the acute invasive fungal sinusitis developed from a sphenoid sinus fungal ball. The patient was treated with antimicrobial therapy and transnasal endoscopic surgery twice to decompress the orbital apex, drain the abscess and obtain specimens for analysis. The right-sided ptosis, visual loss, ophthalmoplegia, and headache resolved entirely. No immune or comorbid diseases were identified, microbiological and histopathological analyses were negative, and MRI could not be performed on the presented patient. For that reason, the diagnostic procedure was non-standard. Nevertheless, the treatment outcome of this vision and life-threatening disease was satisfactory. Treating the fungal ball in an older or immunocompromised patient is essential to prevent invasive fungal rhinosinusitis and fatal complications.

Orbital apex syndrome secondary to apical periodontitis of a tooth: a case report

BACKGROUND

Orbital apex syndrome (OAS) is a rare disease with a noticeable mortality rate. Although its etiology has been repeatedly assessed, few reports have concentrated on odontogenic infection. We presented a rare case of OAS secondary to apical periodontitis.

CASE PRESENTATION

A 61-year-old male was admitted to our hospital for a 3-day history of left orbital and head pain, along with diplopia for 1-day. He also had toothache symptoms before his admission. Due to the atypical early symptoms of orbital apex and cranial nerve injury, no timely and effective diagnosis and treatment were initially provided. However, as the disease progressed and complications occurred, we timely adjusted the diagnosis and successfully controlled the infection. During the one-year follow-up, no recurrence of inflammation was observed; nevertheless, the ptosis and ophthalmoplegia persisted.

CONCLUSIONS

OAS is a rare, while severe complication of odontogenic infection. This case had various symptoms and nerve injury in the orbital apical area. When disease is atypical in its early stages, treatment is easily overlooked. Early detection and suspicion of orbital apex-related complications should be heightened.

Bridging the Gap between Ophthalmology and Emergency Medicine in Community-Based Emergency Departments (EDs): A Neuro-Ophthalmology Guide for ED Practitioners

Coordination of care for patients with neuro-ophthalmic disorders can be very challenging in the community emergency department (ED) setting. Unlike university- or tertiary hospital-based EDs, the general ophthalmologist is often not as familiar with neuro-ophthalmology and the examination of neuro-ophthalmology patients in the acute ED setting. Embracing image capturing of the fundus, using a non-mydriatic camera, may be a game-changer for communication between ED physicians, ophthalmologists, and tele-neurologists. Patient care decisions can now be made with photographic documentation that is then conveyed through HIPAA-compliant messaging with accurate and useful information with both ease and convenience. Likewise, external photos of the anterior segment and motility are also helpful. Finally, establishing clinical and imaging guidelines for common neuro-ophthalmic disorders can help facilitate complete and appropriate evaluation and treatment.

Acute Bilateral Blindness in the Setting of Sudden Onset of Bilateral Proptosis and Ophthalmoplegia: A Case Report With Literature Review

PURPOSE OF REVIEW

Acute bilateral blindness has an extensive differential diagnosis that requires a careful history and physical examination to narrow down. In this article, we discuss the pathophysiology and radiographic findings of each possible diagnosis for acute bilateral blindness.

RECENT FINDINGS

Visual pathology with respect to bilateral blindness can be broadly broken down into 3 anatomic categories: media (i.e., the anterior and posterior chamber of the eye), retina, and neural visual pathway. Possible causes of rapid onset bilateral blindness include bilateral occipital infarcts, endogenous bacterial endophthalmitis, orbital cellulitis, orbital compartment syndrome, cavernous sinus thrombophlebitis, thyroid disease, and bilateral nonarteritic ischemic optic neuropathy.

SUMMARY

In this case, we present a patient with acute onset of bilateral blindness, in addition to bilateral ophthalmoplegia, proptosis, and orbital chemosis. We believe that this rare case of acute bilateral blindness is thought provoking and aids in the understanding of the differential diagnosis and underlying pathophysiology of visual loss.

Magnetic resonance imaging of the orbit, Part 2: Characterization of orbital pathologies

In this article we focus on a systematic approach to assess common orbital lesions on magnetic resonance imaging (MRI). The identification of the probable compartment or structure of origin helps narrow the differential diagnosis of a lesion. Analyzing the morphology, appearance, and signal intensity on various sequences, the pattern, and degree of contrast enhancement are key to characterize lesions on MRI. Imaging features suggesting cellularity and vascularity can also be determined to help plan for biopsy or surgery of these lesions. MRI can also distinguish active from chronic disease in certain pathologies and aids in selecting appropriate medical management. MRI may thus serve as a diagnostic tool and help in guiding therapeutic strategies and posttreatment follow-up.

Orbital apex syndrome due to invasive aspergillosis in an immunocompetent patient

Infection is a rare cause of orbital apex syndrome (OAS) and most commonly occurs in immunocompromised hosts. We report a case of OAS in an elderly immunocompetent female due to invasive aspergillosis and Staphylococcus aureus co-infection. The patient required both surgical debridement and prolonged courses of antibiotic and antifungal therapy. Invasive fungal disease must be considered in cases of OAS, even in patients without classic risk factors.

[Idiopathic orbital inflammation]

BACKGROUND

Orbital inflammatory disease encompasses a spectrum of disorders. Idiopathic orbital inflammation (IOI) is often a diagnosis of exclusion, which needs to be differentiated from infections, systemic inflammatory disease, and neoplasms. IOI includes anterior inflammation with dacryoadenitis, myositis, perineuritis of the optic nerve, periscleritis, diffuse sclerosing inflammation, and orbital apex inflammation.

OBJECTIVE

A differential diagnostic overview of IOI is presented, including its subcategories, diagnosis, and treatment.

CONCLUSION

The diagnosis of IOI is often made by exclusion with typical clinical findings, CT and MRI scans, and pathology. Treatment includes corticosteroids, immunomodulators, immunosuppressants, and radiotherapy.

A Posttraumatic Dilated, Proptotic Eye Does Not Always Need a Lateral Canthotomy! A Review of Superior Orbital Fissure Syndrome for Emergency Physicians

BACKGROUND

Superior orbital fissure syndrome (SOFS) is a rare constellation of findings consisting of ophthalmoplegia, ptosis, a fixed dilated pupil, forehead anesthesia, and loss of the corneal reflex. This syndrome, though rare, is most often encountered in trauma with individuals sustaining a facial fracture.

CASE REPORT

We present a case of a young woman who was diagnosed with SOFS after a fall in her house, hitting her face on a nightstand. Treatment consisted of high-dose i.v. steroids followed by a taper with close follow-up in the Ophthalmology clinic. We provide a brief review of SOFS, including treatment considerations and follow-up. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: SOFS can be easily overlooked in an individual presenting to the emergency department after facial trauma with proptosis. However, a thorough examination of the eye, visual acuity, and intraocular pressure will focus the physician on SOFS rather than the need for immediate decompression via lateral canthotomy. This report describes a traumatic cause of SOFS, the pathophysiology and treatment, and summarizes existing literature.

Not Just Down and Out: Oculomotor Nerve Pathologic Spectrum

The purpose of this article is to understand the complex pathologic spectrum of oculomotor nerve palsy. We review the detailed anatomy and function of the oculomotor nerve and demonstrate how the location of a lesion can drive the differential diagnosis. Lastly, we review atypical presentations of oculomotor nerve palsy to include oculomotor synkinesis and oculomotor nerve hyperactivity. Radiologists must be aware of the typical and atypical presentations of CN III palsy to accurately localize lesions as well as avoid premature exclusion of CN III pathology.

A systematic review of orbital apex syndrome of odontogenic origin: Proposed algorithm for treatment

Orbital apex syndrome (OAS) can be a rare, but severe complication of an odontogenic infection and has high morbidity and mortality. Antibacterial drugs are typically an appropriate treatment choice, but the most severe cases are fungal in nature and pose a tough challenge to the clinician. The aim of this study was to determine the predisposing factors, specific aspects in its management and the appropriate treatment strategy in order to improve patient outcome. A systematic review was conducted using PubMed, PubMed Central, Web of Science, and Scopus up to February 2020, based on the associations between dental extraction or infections and OAS. Of 721 papers found, 18 articles were considered eligible and presented in total 21 cases (13 fungal and eight bacterial infections). The information was organized into a diagnostic and treatment algorithm which included data extracted both from the included cases and updated literature of treatment efficacy studies. Immunosuppression (uncontrolled diabetes mellitus and chemotherapy) was found as an important predisposing factor particularly for fungal infections. In these cases, we suggest that early simultaneous approaches, including aggressive surgical procedures and systemic administration of amphotericin B, result in a better outcome. In conclusion, medical intervention success depends on aggressive treatment and multidisciplinary teamwork.

Orbital apex syndrome secondary to an orbital sarcoma in a dog

A 12-year-old castrated male cocker spaniel dog was presented with a 4-week history of left episcleral injection and pawing at the face. Clinical examination findings included left internal and external ophthalmoplegia, left dorsal strabismus, pain opening the mouth, and intermittent amaurosis. Imaging studies revealed a left orbital apex mass with adjacent sphenoid bone lysis and extension into the cranial cavity. A left exenteration was performed and histopathology confirmed an orbital soft tissue sarcoma. Key clinical message: This report describes an orbital tumor causing orbital apex syndrome. This condition should be differentiated from cavernous sinus syndrome as the latter does not course with optic neuropathy.

Orbitocranial Penetrating Injury With Multiple Vessel Invasion in an Infant: A Case Report and Literature Review

Orbitocranial penetrating injury (OPI) with multiple vascular invasions is a rare occurrence. To our knowledge, experience with its clinical treatment is rather limited, especially for infants. This case report describes an infant who fell from a 0.5 m high bed and landed on a toy with a keen-edged plastic rod. The fractured end of the rod was noted at the medial aspect of the left eyelid, and she was experiencing impaired consciousness. Computed tomography showed that the foreign body penetrated the cavernous sinus with internal carotid artery involvement, and compressed the transverse sinus through the cerebellum. Emergency surgery was performed with temporal occlusion of the left common carotid artery. The rod was removed from the orbital side, and bleeding from cavernous sinus region was effectively controlled under direct inspection via a sub-temporal approach. The patient was successfully treated and recovered consciousness after 17 days. This is the first report of successful management of OPI combined with multiple vascular injury in an infant. Herein, we highlight the anatomical imaging features of the injuries and also the individualized strategy concerning vascular invasion.

Bilateral facial nerve involvement in a patient with Tolosa–Hunt syndrome

Tolosa–Hunt syndrome is characterized by unilateral retro-orbital headaches and cranial nerve palsies, usually involving cranial nerves III–VI. It is rare for other cranial nerves to be involved, although this has previously been reported. We report a 19-year-old woman presenting with typical features of Tolosa–Hunt syndrome but ultimately developing bilateral facial nerve palsies and enhancement of both facial nerves on magnetic resonance imaging. The patient presented with unilateral retro-orbital headaches and palsies of cranial nerves III–VI. She was diagnosed with Tolosa–Hunt syndrome but was non-compliant with her corticosteroid treatment due to side effects. She returned with progressive left followed by right facial nerve palsy. Her corresponding follow-up magnetic resonance imaging scans showed sequential enhancement of the left and right facial nerves. She ultimately had clinical improvement with IV methylprednisolone. To our knowledge, Tolosa–Hunt syndrome associated with bilateral facial nerve palsy and corroborative facial nerve enhancement on magnetic resonance imaging has not previously been described. Moreover, our patient’s clinical course is instructive, as it demonstrates that this atypical presentation of Tolosa–Hunt syndrome can indeed respond to corticosteroid treatment and should not be mistaken for other entities such as Bell’s palsy.

Expanded exposure and detailed anatomic analysis of the superior orbital fissure: Implications for endonasal and transorbital approaches

This study aimed to ascertain the maximal exposure of the superior orbital fissure (SOF) afforded by combining endonasal and transorbital endoscopic approaches. Six cadaveric specimens (12 sides) were dissected using endonasal and transorbital endoscopic approaches to access the SOF. The order of the approaches was alternated in each specimen (eg, starting with an endonasal approach in one side followed by a transorbital exposure and reversing the order on the contralateral side). Maximal exposure of the SOF and its contents for individual and combined approaches were explored. The endonasal corridor provided adequate access to the inferomedial 1/3 of the SOF and including the proximal segments of cranial nerves (CN) III, V₁ and VI. A transorbital approach was superior accessing the superolateral 2/3's of the SOF, including the superior ophthalmic vein, lacrimal nerve, and distal segment of the CN VI at the lateral aspect; the nasociliary nerve and divisions of CN III centrally; and the frontal nerve and CN IV at the dorsal aspect of levator palpebrae superioris. This study suggests that a combined endonasal and transorbital exposure of the SOF may be advantageous to address lesions in this challenging region.

More than Meets the Eye: Aspergillus-Related Orbital Apex Syndrome

The patient is a 67-year-old Caucasian male with a past medical history of diabetes mellitus type 2, coronary artery disease (CAD) status post stent placement, renal cell carcinoma (RCC) status post left nephrectomy and bilateral adrenalectomy secondary to metastatic disease, and aspergillus pneumonia who was transferred from an outside hospital for evaluation of progressively worsening pulsating right temple and retrobulbar headache. Initial studies ruled out glaucoma, giant cell arteritis, and stroke, or aneurysmal pathology. The only positive finding was right sphenoid sinus disease on imaging that had caused bony destruction and infiltration of the right orbital apex. Broad-spectrum antibiotics were started for bacterial versus fungal sinusitis and the patient was admitted to the medical floor with consultations to Neurology, Otolaryngology (ENT), and Ophthalmology. ENT took the patient emergently to the OR. The final diagnosis was chronic aspergillus sinusitis and right-sided orbital apex syndrome (OAS). Antibiotics and antifungals were optimized by the infectious disease team. ENT also ordered steroid washouts post-operatively with budesonide and saline as well as sinus debridements every couple of weeks.

Orbital Apex Syndrome: A Clinico-anatomical Diagnosis

An 8-month-old girl presented with fever, restricted left eye movements and increasing proptosis for 8 days. On examination she had left orbital cellulitis, relative afferent pupillary defect and ophthalmoplegia. Contrast-enhanced magnetic resonance imaging (MRI) brain with orbits revealed orbital apex syndrome (OAS) with cavernous sinus thrombosis. Orbital apex is located posteriorly in the orbit and characterised by involvement of cranial nerves II, III, IV, VI and ophthalmic division of Vth nerve. The close clinico-anatomical differentials of OAS are cavernous sinus and superior orbital fissure syndrome. The current case was treated successfully with intravenous antibiotics and anticoagulation therapy.

Orbital Apex Syndrome: A Review

Orbital apex syndrome is characterized by vision loss from optic neuropathy and ophthalmoplegia due to the involvement of ocular motor nerves in the anatomical region of the orbital apex. Patients could present with signs and symptoms deriving from the involvement of structures within the orbital apex, the superior orbital fissure or the cavernous sinus. The primary focus of the ophthalmologist should be to locate the lesion and then identify its etiology. Clinical evaluation holds key to diagnosis which is aided then by certain serological and lab investigations and neuro-imaging modalities including brain and orbital MRI (Magnetic Resonance Imaging) with contrast, CT (Computed Tomography) scans. In rare instances, a biopsy may be needed to aid in diagnosis. Treatment depends on what the nature of the lesion is with inflammatory conditions usually responding to steroids and infections to anti-microbial agents. Through this review, the authors attempt to decode the approach to localizing the lesion, the etiopathology and the management of cases of orbital apex syndrome

Asymmetric cavernous sinus enlargement: a novel finding in Sturge-Weber syndrome

PURPOSE

Enlargement of deep cerebral veins and choroid plexus engorgement are frequently reported in Sturge-Weber syndrome. We aim to describe cavernous sinus involvement in patients with this syndrome and to identify possible clinical-neuroimaging correlations.

METHODS

Sixty patients with Sturge-Weber syndrome (31 females, mean age 4.5 years) and 120 age/sex-matched controls were included in this retrospective study. We performed a visual analysis to identify patients with asymmetric cavernous sinus enlargement. Then, we measured on axial T2WI the left (A), right (B), and bilateral (LL) transverse diameters of the cavernous sinus. We calculated the module of the difference |A-B| and the cavernous sinus asymmetry index as the ratio |A-B|/LL. Differences among groups were assessed by Mann-Whitney U and Kruskal-Wallis tests. Clinicoradiological associations were evaluated by Fisher exact test.

RESULTS

We found seven subjects (11.6%) with asymmetric CS enlargement. The |A-B| and cavernous sinus asymmetry index were higher in patients with asymmetric CS enlargement compared with controls and patients without visible CS abnormalities (p_B < 0.05). Asymmetric CS enlargement was always ipsilateral to facial port-wine stains (7/7), and, when present, to leptomeningeal vascular malformations (4/7). It was significantly associated with ipsilateral bone marrow changes (p = 0.013) and dilated veins (p = 0.002). Together with brain atrophy and deep venous dilatation, this sign was associated with neurological deficits (p < 0.05).

CONCLUSIONS

We expanded the spectrum of venous abnormalities in SWS, showing the presence of asymmetric cavernous sinus enlargement in more than one tenth of patients, likely related to increased venous drainage.