J Korean Ophthalmol Soc.  2013 Aug;54(8):1275-1281.

A Case of Orbital Apex Syndrome Induced by Penetrating Orbital Injury with Long-Term Results

• Baek SU
• Lee MJ

Abstract

PURPOSE
To report a case of orbital apex syndrome induced by penetrating orbital injury by a wire with the recovery process and clinical outcomes.
CASE SUMMARY
A 40-year-old female visited our clinic after a penetrating orbital injury through the left inferomedial conjunctiva by a wire. The best corrected visual acuity of the left eye was 0.6, and ptosis and total ophthalmoplegia were observed. The patient showed a dilated pupil, swelling of the optic disc on fundus exam, and an inferior field defect on the automated perimetry. The computed tomography image revealed mild retrobulbar hemorrhage, but there was no orbital bony fracture. Enhancement of the optic nerve sheath was observed on the magnetic resonance image. The patient was admitted and received systemic antibiotics and steroid treatment. After 1 month, visual acuity, ptosis, and limitation in adduction were partly improved. After 3 months, depression and adduction were improved and the pupil size was normalized. However, further improvement was not observed after the one-year follow-up.
CONCLUSIONS
The recovery from orbital apex syndrome was achieved until 3 months after injury. The final outcomes may depend on the mechanism and pathophysiology of the injury. Emergent diagnosis and proper management are essential to achieve optimal clinical results.

Keyword

Orbital apex syndrome; Penetrating orbital injury

MeSH Terms

Anti-Bacterial Agents
Conjunctiva
Depression
Eye
Female
Humans
Magnetic Resonance Spectroscopy
Ophthalmoplegia
Optic Nerve
Orbit
Pupil
Retrobulbar Hemorrhage
Visual Acuity
Visual Field Tests
Anti-Bacterial Agents

Figure

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  Figure 1. Fields of gazes on initial presentation show limitation of the extraocular muscle movement in all directions. Complete pto-sis of the left upper eyelid is also noted.

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  Figure 2. (A) Optic disc photograph, OCT, and visual field test findings on initial presentation. Optic disc photograph (upper left) demonstrates whitish elevation at the superior disc margin. OCT (upper middle) findings show increase thickness of the superior RNFL which correlated with the optic disc photographs. Automated perimetry (upper right) reveals inferior altitudinal visual field defects on the gray-scale. (B) One month after injury, optic disc photograph shows no significant change. However, OCT shows the thickness of superior RNFL reduced to the normal range, and the visual field defects also improved accordingly. OCT = optical co-herent tomography; RNFL = retinal nerve fiber layer.

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  Figure 3. Axial (left) and coronal (right) CT scan on initial presentation. CT demonstrates an increased reticular pattern with-in the right intraconal fat and around the postlaminar optic nerve suggesting mild retrobulbar hemorrhage (arrow). There is no orbital bony fracture.

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  Figure 4. Axial (left) and Coronal (right) MRI (T2 weighted image) scan on 1 day after injury. The optic nerve sheath and retrobulbar fat of the left eye show prominent enhancement. The remaining findings are nonspecific.

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  Figure 5. Field of gaze at 1 year after injury. Ptosis of the left upper eyelid partially improved. Abduction of the left eye recovered completely and adduction and depression also partially improved. However, elevation of the left eye was still limited.

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