Orbital apex syndrome (OAS) is a rarely described disorder that may develop as a complication of various conditions, including trauma of the craniomaxillofacial area, malignant disorders of the orbit (rhabdomyosarcoma and lymphoma being the two most common neoplasias), infections (such as herpes zoster ophthalmicus or fungal invasion), and inflammatory changes, either isolated or systemic (eg. Wegener's granulomatosis, sarcoidosis, and polyarteritis nodosa) [1] [2] [3] [4] [5]. This ailment can be seen in any decade of life, with some studies establishing a mean age of 45-50 years [2]. The typical signs stem from pathological effects of the conditions on the structures that pass through the superior orbital fissure and the orbital apex - cranial nerves supplying the extraocular muscles (trochlear, oculomotor, and abducens nerves) and the surrounding anatomical landmarks (numerous divisions of the trigeminal nerve), as well as the optic nerve and blood vessels [1] [5]. According to certain reports, blurred vision arising from reduced visual acuity and a fixed dilated pupil is the most frequent symptom in OAS [2] [3]. In addition, proptosis (eye protrusion), ptosis, reduced sensation on the forehead (hypoesthesia), hyposecretion from the lacrimal apparatus, and diplopia or even vision loss are other notable features [6] [7].

• Hodgkin Lymphoma

  non-Hodgkin lymphoma, leukemia Perineural invasion of cutaneous malignancy: squamous cell cancer Iatrogenic/Traumatic – Traumatic/Iatrogenic causes can lead to orbital apex syndrome via direct or indirect injury. [eyewiki.aao.org]

  Hematologic: Burkitt lymphoma, non-Hodgkin lymphoma, leukemia 5. Perineural invasion of cutaneous malignancy Etiology of Orbital Apex Syndrome 26. [slideshare.net]

• Anemia

  Sickle cell anemia Etiology of Orbital Apex Syndrome 24. Infectious 1. Fungi: Aspergillosis, Mucormycosis 2. Bacteria: Streptococcus spp., Staphylococcus spp., Actinomyces spp., Gram-negative bacilli, anaerobes, Mycobacterium tuberculosis 3. [slideshare.net]

  After the body stores of vitamin B12 are depleted, patients may begin to show signs of the anemia. 1975;123805-14. GC can cause a significant keratitis in newborn children and adults, so prompt identification and treatment are paramount. [luxbar-starway.ru]

• Conjunctival Injection

  Proptosis with or without orbital congestion Chemosis and/or conjunctival injection Differential diagnosis Superior Orbital Fissure Syndrome (SOFS) SOFS may involve any of the structures coursing through the superior orbital fissure anterior to the orbital [eyewiki.aao.org]

  Slit-lamp exam showed right conjunctival injection, corneal edema and a hyphema with neovascularization of the iris. There was dense nuclear sclerosis and vitritis that precluded fundoscopic examination. [reviewofophthalmology.com]

• Eye Pain

  A woman with right eye pain and vision loss. Baker JP, Maldonado N, Rho J. Baker JP, et al. J Am Coll Emerg Physicians Open. 2022 Nov 29;3(6):e12863. doi: 10.1002/emp2.12863. eCollection 2022 Dec. J Am Coll Emerg Physicians Open. 2022. [pubmed.ncbi.nlm.nih.gov]

  (23%), headache (17%), periorbital pain (11%) or eye pain (8%)  MRI and CT aid in diagnosis, however confirmed only on biopsy and HPE. [slideshare.net]

• Swelling of Eyelid

  The presence of proptosis, with swelling of eyelids and chemosis (swelling of ocular surface membranes), indicates significant mass extension within the orbit. [jnnp.bmj.com]

• Epistaxis

  A 34-year-old man with severe, recurrent epistaxis underwent external anterior and posterior ethmoidal artery ligation on the right side. Visual loss from optic neuropathy and complete ophthalmoplegia developed after surgery. [ncbi.nlm.nih.gov]

  The patient, a known HIV-1 seropositive male, presented with a six-month history of mass in nose, headache and repeated epistaxis. [ijpmonline.org]

  Although direct CCFs are usually not thought to be mobci, mobic 100 are numerous reports of patients experiencing significant and even fatal epistaxis, mobc hemorrhage. 5 mgday at night- time because of lack of response to various anxiolytics; he developed [luxbar-starway.ru]

The diagnosis of orbital apex syndrome can be made early on with a detailed history taking and a proper physical examination. Firstly, the physician should assess the onset of complaints and their progression, whereas a detailed inspection of the orbit and a thorough neurological examination may provide solid evidence to make a presumptive diagnosis. Typical findings encountered during the exam are ophthalmoplegia, decreased corneal reflex (a sign of trigeminal nerve palsy) and a variable degree of visual impairment [1] [7]. Imaging studies must be employed whenever these symptoms are present. Plain radiography, apart from its beneficiary role in delineating skeletal trauma and fractures, possesses a limited capacity to discriminate between different etiologies, which is why computed tomography (CT), particularly helical CT (sometimes with iodine as a contrast agent) is recommended for assessing signs pointing to orbital apex syndrome [1]. Gadolinium-enhanced magnetic resonance imaging (MRI), however, is a superior technique that allows a more detailed evaluation of the soft tissues and the vascular structures that may be further examined through MR or CT angiography [1] [7]. In the absence of a clear underlying cause, a thorough laboratory workup must be carried out, including a complete blood count (CBC), serum electrolytes and inflammatory parameters (C-reactive protein and erythrocyte sedimentation rate), antinuclear and extractable nuclear antibodies (ANA and ENA, respectively), antineutrophilic antibodies (ANCAs), angiotensin-converting enzyme (ACE), and serum protein electrophoresis [1].

• Staphylococcus Aureus

  He underwent urgent drainage of the abscess and Staphylococcus aureus was identified with Gram stain. He was systemically administered intravenous antibiotics and steroids. [ncbi.nlm.nih.gov]

  Although nasal septal abscess is uncommon, the organism most likely to cause nasal septal abscess is Staphylococcus aureus, and fungal septal abscesses are rare. [bmcinfectdis.biomedcentral.com]

  Finally pupils become sluggish, extraocular palsies develop, acuity diminishes, and contralateral signs emerge.  Most cases occur in previously healthy persons, though diabetes predisposes.  Staphylococcus aureus is the most frequent causal organism [slideshare.net]

  Staphylococcus aureus is the most frequent causal organism though pneuomococci and fungi can be encountered. [jnnp.bmj.com]

• Treponema Pallidum

  pallidum Viruses: Herpes Zoster Neoplastic Head and neck tumors: nasopharyngeal carcinoma with extension into the orbit, primary orbital adenoid cystic carcinoma with extension to the orbital apex Neural tumors: neurofibroma, meningioma, ciliary neurinoma [eyewiki.aao.org]

  Spirochetes: Treponema pallidum 4. Viruses: Herpes zoster Traumatic 1. Penetrating injury 2. Non penetrating injury 3. Orbital apex fracture 4. Retained foreign body 25. Iatrogenic 1. Sinonasal surgery 2. Orbital/facial surgery Neoplastic 1. [slideshare.net]

• Alternaria

  Fungi reported to cause fungal sinusitis in AIDS patients include Aspergillus species, Schizophyllum commune, Cryptococcus neoformans, Candida albicans, Rhizopus arrhizhus and Alternaria alternate and Pseudoallescheria boydii. [2] There are 26 cases of [ijpmonline.org]

• Candida

  Fungi reported to cause fungal sinusitis in AIDS patients include Aspergillus species, Schizophyllum commune, Cryptococcus neoformans, Candida albicans, Rhizopus arrhizhus and Alternaria alternate and Pseudoallescheria boydii. [2] There are 26 cases of [ijpmonline.org]

• Actinomyces Israelii

  Bilateral cavernous sinus involvement has also been reported in association with central nervous system Actinomyces israelii.  Management comprises appropriate antibiotic treatment supplemented by anticoagulation to prevent septic emboli, steroids to [slideshare.net]

In addition to our case, we review the clinical presentation, imaging findings, treatment options, and prognosis of 14 other reported cases. [ncbi.nlm.nih.gov]

Mega dose corticosteroid treatment for traumatic superior orbital fissure and orbital apex syndromes. Ann Plastic Surg 2004; 53: 60-4. [jpma.org.pk]

Patients with ocular motor deficits in orbital apex syndromes caused by extension of nasopharyngeal rhabdomyosarcoma have an excellent prognosis for recovery after treatment of the tumor. The long-term prognosis for visual recovery, however, is poor. [ncbi.nlm.nih.gov]

We discuss rhino-orbital mucormycosis in detail, because it has a grave prognosis if it is not diagnosed and treated in a timely fashion. Access to the complete content on Oxford Medicine Online requires a subscription or purchase. [oxfordmedicine.com]

Etiology [1] variety of etiologies and detailed history is important in narrowing the differential diagnosis. [eyewiki.aao.org]

A systematic approach to the evaluation of eye symptoms is necessary to identify the etiology and to initiate treatment. An extensive list of etiologies causing OAS has been reported 1. [jpma.org.pk]

The discussion covers the phenotype spectrum, epidemiology, mode of inheritance, pathogenesis, and clinical profile of each condition, all of which is accompanied by a wealth of illustrations. [books.google.com]

Epidemiology It is a rare condition and most of the literature is case reports rather than series [ 2, 3 ]. The estimated incidence of Tolosa Hunt syndrome (THS) is about one case per million per year [ 4 ]. [patient.info]

Dufour X, Kauffmann-Lacroix C, Ferrie JC, Goujon JM, Rodier MH, et al. (2006) Paranasal sinus fungal ball epidemiology, clinical features and diagnosis. A retrospective analysis of 173 cases from a single center in France, 1989-2002. [omicsonline.org]

RegelmaМГige Kontrollen des Schrittmachers sind acyclovir interactions medications. 446 Epidemiology. Brezincch. Renal vein thrombosis after martial arts trauma. Anz. Ast. [masa42.ru]

Epidemiological profile of 277 patients with facial fractures treated at the emergency room at the Ent 248 5 Department of Hospital do Trabalhador in Curitiba/PR, in Int Arch Otorhinolaryngol. 2012; 16(4): Gabikian P, Chowdhary AM, Kott B, Lazar DA, Britz [docplayer.es]

The variable pathophysiology of acute orbital compartment syndrome has not been elucidated fully. [emedicine.medscape.com]

[…] from high impact forces. [6] Iatrogenic: sinonasal surgery, orbital/facial surgery Traumatic: penetrating, nonpenetrating, orbital apex fracture Vascular Carotid cavernous aneurysm, carotid cavernous fistula, cavernous sinus thrombosis Other: Mucocele Pathophysiology [eyewiki.aao.org]

Prompt diagnosis and treatment in cases of orbital apex syndrome, especially in immunocompromised patients, is important to prevent visual and life-threatening complications. [ncbi.nlm.nih.gov]

Our aim is to emphasize the importance of good glycemic control during any invasive procedure in a diabetic patient, to prevent any dreadful complications. References Kim IK, Kim JR, Jang KS, Moon YS, Park SW. [djo.org.in]

V. 1 Without undergoing screening or preventive action, D, Doebbeling, B. [skoncept.ru]

Supported in part by Research to Prevent Blindness, Inc, New York, NY; Fund for the New Jersey Blind, Newark, NJ; Lions Eye Research Foundation of New Jersey, Newark, NJ; The Eye Institute of New Jersey, Newark, NJ; and the Gene C. [healio.com]

1. Bone I, Hadley D. Syndromes of the orbital fissure, cavernous sinus, cerebello-pontine angle, and skull base. J Neurol Neurosurg Psychiatry. 2005;76(Suppl 3):iii29-iii38.
2. Aryasit O, Preechawai P, Aui-Aree N. Clinical presentation, aetiology and prognosis of orbital apex syndrome. Orbit. 2013;32(2):91-94.
3. Sugamata A. Orbital apex syndrome associated with fractures of the inferomedial orbital wall. Clin Ophthalmol. 2013;7:475-478.
4. Kurimoto T, Tonari M, Ishizaki N, et al. Orbital apex syndrome associated with herpes zoster ophthalmicus. Clin Ophthalmol. 2011;5:1603-1608.
5. Imaizumi A, Ishida K, Ishikawa Y, Nakayoshi I. Successful Treatment of the Traumatic Orbital Apex Syndrome due to Direct Bone Compression. Craniomaxillofac Trauma Reconstr. 2014;7(4):318-322.
6. Warburton RE, Brookes CC, Golden BA, Turvey TA. Orbital apex disorders: a case series. Int J Oral Maxillofac Surg. 2016;45(4):497-506.
7. Gupta R, Khan YA. Traumatic orbital apex syndrome. Can J Ophthalmol. 2015;50(1):e8-e11.