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NEUROIMAGING
Year : 2020  |  Volume : 15  |  Issue : 3  |  Page : 336-337
 

Orbital apex syndrome: a clinico-anatomical diagnosis


1 Division of Child Neurology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
2 Department of Radiodiagnosis, Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India

Date of Submission08-May-2020
Date of Decision04-Jul-2020
Date of Acceptance15-Jul-2020
Date of Web Publication06-Nov-2020

Correspondence Address:
Prof. Sheffali Gulati
Centre of Excellence and Advanced Research on Childhood Neurodevelopmental Disorders, Division of Child Neurology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpn.JPN_114_20

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   Abstract 

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.


Keywords: Cavernous sinus, orbital apex, superior orbital fissure


How to cite this article:
Saini L, Chakrabarty B, Kumar A, Gulati S. Orbital apex syndrome: a clinico-anatomical diagnosis. J Pediatr Neurosci 2020;15:336-7

How to cite this URL:
Saini L, Chakrabarty B, Kumar A, Gulati S. Orbital apex syndrome: a clinico-anatomical diagnosis. J Pediatr Neurosci [serial online] 2020 [cited 2020 Nov 24];15:336-7. Available from: https://www.pediatricneurosciences.com/text.asp?2020/15/3/336/300036




A premorbidly normal, 8-month-old girl, presented with fever, progressive proptosis, and restriction of left-sided ocular movements of 1 week. Salient features on examination were left-sided orbital cellulitis, relative afferent pupillary defect, and ophthalmoplegia. Clinically, a possibility of left orbital cellulitis with involvement of left orbital apex and/or cavernous sinus was kept.

Contrast-enhanced magnetic resonance imaging (MRI) of the brain and orbit revealed inflammation of the left orbit with extension to the optic nerve, orbital apex, and cavernous sinus, confirming the diagnosis of orbital apex syndrome (OAS) with additional left cavernous sinus thrombosis [Figure 1].
Figure 1: Contrast-enhanced axial (A, B) and coronal (C) MRI of the brain shows proptosis of left eye globe with enhancing inflammation in left orbit and at the orbital apex (arrow in B) with extension into left cavernous sinus (arrows in A and C)

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Orbital apex is anatomically located in the posterior part of a pyramidal-shaped orbit.[1] The OAS is characterized by the involvement of cranial nerves II, III, IV, VI, and ophthalmic division of Vth.[2] Owing to the close anatomical proximity, it needs to be differentiated from superior orbital fissure syndrome (SOFS) and cavernous sinus syndrome (CSS). The presence of optic nerve involvement differentiates OAS from the other two. Involvement of sympathetic fibers and maxillary division of trigeminal nerve differentiates CSS from the others.[3] This case had an involvement of orbital apex with the extension of the disease process to cavernous sinus.

The OAS can be caused by infective, inflammatory, endocrine, neoplastic, and vascular causes.[4] Management revolves around the treatment of the underlying cause and tissue diagnosis, whenever required.[1],[2] This case responded to 12 weeks of intravenous antibiotics and subcutaneous low-molecular-weight heparin for the associated cavernous sinus thrombosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Badakere A, Patil-Chhablani P Orbital apex syndrome: a review. Eye Brain 2019;11:63-72.  Back to cited text no. 1
    
2.
Yeh S, Foroozan R Orbital apex syndrome. Curr Opin Ophthalmol 2004;15:490-8.  Back to cited text no. 2
    
3.
Kline LB The Tolosa-Hunt syndrome. Surv Ophthalmol 1982;27:79-95.  Back to cited text no. 3
    
4.
Goyal P, Lee S, Gupta N, Kumar Y, Mangla M, Hooda K, et al. Orbital apex disorders: imaging findings and management. Neuroradiol J 2018;31:104-25.  Back to cited text no. 4
    


    Figures

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