1. Clinical anatomy of the superior orbital fissure and the orbital apex
Jerzy REYMOND1
, Jan KWIATKOWSKI2
, Jaros1aw WYSOCKI3,4
1
Department of Maxillofacial Surgery, Specialist Hospital in Radom, Poland; 2
Department of Ophthalmology,
Specialist Hospital in Radom, Poland; 3
Clinic of Otolaryngology and Rehabilitation, II Medical Faculty,
Warsaw Medical University Poland; 4
Institute of Physiology and Pathology of Hearing, Warsaw, Poland
SUMMARY. Background: There are discrepancies between authors as far as topography of superior ophthalmic
vein in the orbital apex is concerned. Objectives: The aim was to determine the location of the structures
within the posterior part of the orbit and in the superior orbital fissure. Material: One hundred preparations
of orbits were derived from the corpses sectioned in Forensic Medicine Department, University Medical School in
Warsaw, Poland. Study design: Anatomical preparation was performed with use of standard set of microsur-
gical equipment and operating microscope. Results: Nine various morphological types of the superior orbital
fissure were distinguished. Among those were two main categories: type ‘‘a’’ characterised by a clear narrowing
within the fissure and type ‘‘b’’ which lacked such narrowing. The type ‘‘a’’ and ‘‘b’’ fissures were also different
in length whereby type ‘‘b’’ fissure was significantly shorter. A diversity of positioning of the soft structures
within those types was successfully noted. In type ‘‘a’’ the superior ophthalmic vein was located typically, how-
ever in type ‘‘b’’ fissures it was significantly more often the lowest structure in the posterior part of the orbital
apex (except for muscles and orbital fat). A short case report of patient with superior orbital syndrome was
added. Conclusion: Position of soft tissue structures in superior orbital fissure depended on its morphological
type. Ó 2008 European Association for Cranio-Maxillofacial Surgery
Keywords: superior orbital fissure, orbital apex syndrome, anatomy, dimensions, case report
INTRODUCTION
Orbital anatomy, however described in anatomy text-
books, is in need of updating from the current literature
and clinical experiences. Aside from a few books and ar-
ticles on orbital anatomy (Natori and Rhoton, 1994,
1995; Ettl et al., 1997, 2000; Ucerler and Govsa, 2006;
Nagasao et al., 2007), there are clinical reports which re-
fer to the subject only in a narrow content. There is a lack
of thorough and exhaustive investigation into the topo-
graphical anatomy of the superior orbital fissure, espe-
cially regarding potentially serious complications
occurring postoperatively (Cruz and dos Santos, 2006).
The superior orbital fissure is a small but topographi-
cally important area, which connects the middle cranial
fossa and the orbit (Lang, 1979; Bergin, 1987; Natori
and Rhoton, 1994, 1995; Williams and Bannister, 1995;
Govsa et al., 1999). The fissure is divided into clear topo-
graphical divisions. Some researchers distinguish only
two compartments (Bergin, 1987; Morard et al., 1994;
Govsa et al., 1999; Shapiro and Robinson, 1967). The
superior orbital fissure consists of the following components:
- Superior or superolateral part which includes the troch-
lear, lacrimal, frontal nerves and the superior ophthal-
mic vein.
- Inferior or inferomedial part which includes the superior
and inferior branches of the oculomotor nerve, the
nasociliary nerve, the abducens nerve. Here also lies
the sensory root and the sympathetic root of the ciliary
ganglion. The inferior ophthalmic vein, if it is present
here, can at times pass through the tendinous annulus
of Zinn.
This division originates in the very shape of the fissure
in which in most cases a long and narrow lateral part and
broad and shorter medial part can be observed. This
division is stressed even further by the tendinous annulus
of Zinn. The location of the contents within the fissure is
fairly constant. The superior branch of the oculomotor
nerve is the structure closest to the medial rim of the fis-
sure; the trochlear nerve is the closest to the superior rim
and the abducens nerve is the closest to the inferior rim
(Govsa et al., 1999).
Others state that three separate compartments within
the fissure can be distinguished: lateral, medial and infe-
rior (Natori and Rhoton, 1994, 1995; Ettl et al., 1997,
2000). The lateral component is consistent with the nar-
row part of the superolateral fissure and contains the
trochlear nerve, the frontal nerve, the lacrimal nerve
and the superior ophthalmic vein. The medial part is con-
sistent with the tendinous annulus of Zinn and contains
the superior and inferior branches of the oculomotor
nerve as well as the nasociliary nerve, the abducens nerve
and the roots of the ganglion. The inferior part lies below
the tendinous annulus and is mainly filled with the adi-
pose tissue; the inferior ophthalmic vein is located here
as well (Natori and Rhoton, 1995). According to Ettl
et al. (1997, 2000), the superior ophthalmic vein passes
through the medial part. This observation was drawn
346
Journal of Cranio-Maxillofacial Surgery (2008) 36, 346e353
Ó 2008 European Association for Cranio-Maxillofacial Surgery
doi:10.1016/j.jcms.2008.02.004, available online at http://www.sciencedirect.com

2. from analysis of magnetic resonance imaging (MRI) im-
ages, however, it has only been confirmed by Bergin
(1987).
The pathological processes may occur in the superior
orbital fissure have variable symptomatology (Bowerman,
1969; Ferguson, 1974; Pogrel, 1980; Sieverink and van
der Wal, 1980; Miller, 1985; Zachariades et al., 1985;
Ghobrial et al., 1986; Ettl et al., 2000; Fauci et al.,
1983; Hedstrom et al., 1974). Among them there are syn-
dromes of the orbital apex, the superior orbital fissure and
cavernous sinus. The orbital apex syndrome affects the
cranial nerves: II, III, IV, V1 and VI. The superior orbital
fissure syndrome involves: III, IV, V1 and VI. The cavern-
ous sinus syndrome affects III, IV, V1, V2, VI and the sen-
sory plexus of the ophthalmic artery. The superior orbital
fissure and the orbital apex syndromes usually occur to-
gether.
The research aim was to determine the location of the
structures which pass through the superior orbital fissure
which regard to preferred points of measurement and to
provide clinically useful information. Another important
goal of the research was to establish if there is a signifi-
cant connection between the distribution of vascular and
neural elements within the fissure and its morphological
shape and type.
MATERIALS AND METHODS
One hundred human orbit preparations were collected: 50
female and 50 male adult cadavers. In each group there
were 25 left orbits and 25 right orbits. All were obtained
during regular medical autopsies. The samples for the re-
search were selected from consecutively performed autop-
sies. Possible head-injuries and cases of skull fractures
were excluded. After opening the skull, the bone unit en-
compassing about 1/3 of the posterior part of the orbit, the
lateral wall of sphenoid body and all bony margins of su-
perior orbital fissure were removed. Specimens were then
fixed in a 10% formalin solution; the bony unit was dis-
sected with standard microsurgical tools under the micro-
scope. The shape of the orbital fissure was analysed: nine
basic morphological types AeI and two general types ‘‘a’’
and ‘‘b’’ were determined. The maximum length and
width of the fissure were measured, according to Fig. 1.
Then, using a graticule, distances between margins of
the fissure, and between the optic nerve and bony ridges
of fissure were measured, as in Figs. 1 and 2. All the mea-
surements were made to methric 0.1 mm. After dissection
of all the structures within the orbit had been completed,
the topographical arrangement of structures in the orbital
apex was determined.
Themeasurementsandobservationresultswereanalysed
statistically; first, the descriptive statistical values were cal-
culated(range,mean,andstandarddeviation[SD]).Thedif-
ferences among the calculated mean values were analysed
using Student’s t-test. The differences between non-
parametric features were analysed using chi-squared test.
The results were presented as diagrams and tables and com-
pared with the data provided from the literature.
RESULTS
The morphological variants of the superior orbital fissure
are represented in Fig. 3. In our research, the superior
Fig. 1 e Superior orbital fissure measurements scheme. (a) Maximum
length of the fissure and (b) maximum width of the fissure.
Fig. 2 e Scheme of measurements determining location of optic nerve regarding optic canal and superior orbital fissure with the types ‘‘a’’ and ‘‘b’’
distinguished. (a) Distance from the optic nerve centre to the upper margin of optic canal wall, (b) distance from the optic nerve centre to the medial pole
of superior orbital fissure, (c) distance from the optic nerve centre to the lateral pole of the superior orbital fissure, (d) distance from the optic nerve
centre to the point determined by the narrowing of the fissure (type ‘‘a’’) or the point lying in the middle of line between lateral and medial pole of the
fissure. (1) Optic nerve, (2) content of superior orbital fissure, (3) content of optic canal.
Superior orbital fissure 347

3. orbital fissure had very different shapes: from a classical
fissure-like shape (Fig. 3f), through different triangular
variations and finally, on egg-shaped fissure (Fig. 3I).
The morphological types of the superior orbital fissure
did not present any statistically important variants with
regard to sex and body side. The general rule was that
the shape of the fissure remained the same on both sides
of the skull, the differences in a particular skull related
only to the size of the fissure only.
The size of the superior orbital fissure did not show sta-
tistically important differences regarding sex, side or the
morphological type of the fissure. Analysis showed that
generally there are only two morphologically different
types of the superior orbital fissure. Types FeI (Fig. 3)
share the same characteristics: they do not have a clear nar-
rowing, therefore it was impossible to measure the small-
est width of the fissure as both of its edges meet at one
outermost point (Fig. 2b). On the other hand, types AeE
had a noticeable narrowing that indicates a more or less
clear borderline between the middle broaden part and
the lateral narrow part. In such cases, it was always possi-
ble to find a point at which the fissure was narrowed
(Fig. 2a). This type of fissure was also characterised by
relatively greater length and width. Fissures AeE were
grouped into one type and named type ‘‘a’’; fissures FeI
were grouped as the morphological type ‘‘b’’. Type ‘‘a’’
occurred in 63 preparations and type ‘‘b’’ in 37. Type
‘‘a’’ had a mean length of 17.47 mm (SD ¼ 2.26) and
7.31 mean width (SD ¼ 2.34). Type ‘‘b’’ measured
12.48 mm (mean length, SD ¼ 3.15) and 7.86 (mean)
width (SD ¼ 2.45). Both types ‘‘a’’ and ‘‘b’’ differed sig-
nificantly in the maximal length of the fissure. Regarding
the maximum width of the fissure, the differences were
small and irrelevant. The next research aim was to observe
if there was any connection between the two fissure types
‘‘a’’ and ‘‘b’’ regarding the arrangement of the contents the
fissure and the orbital apex.
The results of measurements between the optic nerve
and its neighbouring structures show no important differ-
ences (Table 1). This encouraged further analysis focused
on the type of fissure. Therefore the data were calculated
separately for the orbital fissures of types ‘‘a’’ and ‘‘b’’
(Table 2). Except for the distance measured from the supe-
rior edge of the optic canal, all other results varied signif-
icantly (they were considerably smaller in type ‘‘b’’). The
distances from the optic nerve to the narrowing as well as
from the lateral rim of the fissure are of great clinical value
for surgeons. They should consider the position of the op-
tic nerve and other adjacent structures closer to the fissure
rim. It is particularly important when the orbit and the cra-
nial cavity are accessed laterally.
In the research material, the following variants of the
orbital apex structures were distinguished. The typical
or ‘‘classical’’ arrangement was based on a clear distinc-
tion of an area limited by the tendinous annulus of Zinn.
The superior ophthalmic vein was situated in the supero-
lateral area, often in the narrow part of the superior
orbital fissure.
The location of the ophthalmic artery varied in relation
to the stem of the optic nerve. Often the artery was infe-
rior to the nerve, but this was observed in only 34 cases.
In 66 cases, the artery was lateral and superior, a typical
variant on occurring when it traverses the optic nerve
from above. In a few preparations (two rights and one
left), the artery was placed laterally, close in the superior
ophthalmic vein (Figs. 4 and 5). Orbital apex nerves
branched in different ways. Often division took place
early, posteriorly in orbit at the level of the tendinous an-
nulus, the frontal nerve divided into the suprafrontal and
Fig. 3 e Scheme of morphological forms of the superior orbital fissure
with percentage in brackets.
Table 1 e Distances between the optic nerve and certain points in optic canal and superior orbital fissure (according to Fig. 2)
Measured distances (in
mm) of the optic nerve
from reference points
M (N ¼ 50) F (N ¼ 50) M + F
L + R
(N ¼ 100)L R L R
a 1.76 (0.92) 1.70 (0.98) 1.68 (0.9) 1.78 (1.01) 1.73 (1.01)
0.7e3.3 1.1e4.0 1.2e4.3 1.0e4.2 0.7e4.3
b 11.02 (1.18) 10.74 (1.12) 10.8 (1.89) 11.01 (1.99) 10.88 (2.17)
8.1e7.6 4.4e13.5 6.0e12.8 7.8e14.2 4.0e17.6
c 16.81 (2.26) 17.23 (2.45) 17.12 (2.83) 16.92 (2.27) 16.84 (2.95)
11.5e21.2 9.3e24.6 12.4e23.2 12.1e22.2 9.2e24.6
d 8.89 (1.45) 9.12 (1.24) 9.16 (1.35) 9.98 (1.29) 9.28 (1.51)
4.1e12.2 4.2e13.5 6.8e16.0 6.4e13.8 4.1e16.0
Arithmetic means are expressed in bold letters, SDs are in parentheses, and ranges of obtained values are given below.
348 Journal of Cranio-Maxillofacial Surgery

4. the supratrochlear nerves, and the branches of the oculo-
motor nerve split into its muscular ramifications. The
abducens nerve showed the greatest constancy in terms
of its location. In all cases, it was found in the middle
part of the lateral rectus muscle.
On rare occasions, an unusually low position of the su-
perior ophthalmic vein was observed. In such cases, the
vein was the lowest structure in the orbital apex near
the superior orbital fissure (Fig. 6). This atypical layout
occurred six times (6% of sides, two right, four left, three
males and three females). The position of the vein was
eight times low and lateral to the abducens nerve, and
on its level. Such a layout was observed in five male
orbits and three female (three right and five left). Those
unusual, low locations of the superior ophthalmic vein
were observed almost exclusively in type ‘‘b’’ fissures,
i.e., broad and short (12/14 type ‘‘b’’ fissures).
The layouts of the structures situated in the orbital
apex are presented in Fig. 7.
DISCUSSION
There is great variation of the superior orbital fissure as
described in the literature. Most of the authors distin-
guish 9 or 10 morphological forms of the superior orbital
fissure (Kornblum and Kennedy, 1942; Shapiro and Jan-
zen, 1960; Sharma et al., 1988; Govsa et al., 1999). Par-
ticular variants occur according to different authors with
the following frequency: 1.5e40%, so the real discus-
sion on frequency of occurrence of each variant is very
difficult, however our results are generally close to previ-
ous observations. An entirely new finding in this research
is the proposed distinction of two substantially different
types of fissure: type ‘‘a’’ has a noticeable narrowing
caused mainly by a bulge (of various size or a bony sur-
plus) on the inferior rim; type ‘‘b’’ has a smooth outline
without any noticeable narrowing. It turns out that both
Table 2 e Distances between the optic nerve and certain measurement
points in the optic canal and superior orbital fissure (according to Fig. 2)
with two types of the fissure distinguished
Measured
distances to the
optic nerve from
reference points
(in mm)
Type ‘‘a’’
(N ¼ 63)
Type ‘‘b’’
(N ¼ 37)
a 1.68 (0.92) 1.81 (0.9)
0.7e4.3 0.98e4.2
b 13.07 (1.18) 7.15 (1.69)
8.2e17.6 4.0e13.1
c 19.43 (2.19) 12.43 (2.34)
13.8e24.6 9.23e17.05
d 7.38 (2.15) 12.51 (2.1)
4.1e11.3 8.2e16.0
Arithmetic means are represented in bold with SD (in parentheses) and
range is given below.
Fig. 4 e Fragment of human orbit. Right side, anterior view.
Arrangement of the structures within the orbital apex. 1 mm gauge
below. (1) Lacrimal nerve, (2) frontal nerve (with two subdivisions), (3)
trochlear nerve, (4) levator palpebrae muscle, (5) short ciliary nerves, (6)
optic nerve, (7) ophthalmic artery, (8) inferior branch of the oculomotor
nerve (subdivided into two branches), (9) abducent nerve, (10)
nasociliary nerve, (11) superior ophthalmic vein, (12) lacrimal vein, (13)
superior branch of the oculomotor nerve.
Fig. 5 e Fragment of human orbit. Right side, anterior view. Superior
orbital fissure type ‘‘a’’. Ophthalmic artery located superiorly and
laterally to the optic nerve. 1 mm gauge below. (1) Lacrimal nerve, (2)
frontal nerve (with two subdivisions), (3) trochlear nerve, (4) levator
palpebrae muscle, (5) rectus superior muscle, (6) superior branch of the
oculomotor nerve, (7) optic nerve, (8) inferior branch of the oculomotor
nerve (subdivided into two branches), (9) lateral rectus muscle, (10)
abducent nerve, (11) nasociliary nerve, (12) superior ophthalmic vein.
Superior orbital fissure 349

5. types of the orbital fissure differ not only with regard to
their shape but also size. Moreover, in both cases the soft
structures are arranged differently. This refers first of all
to the position of the superior ophthalmic vein. In type
‘‘b’’ it was placed noticeably more often in atypical
low or very low position. This observation is of great
clinical importance, as according to classical definitions,
the vein lies in the farthest segment of the fissure. Al-
though we do not usually expect to come across impor-
tant structures passing through this area, the surgeon
should approach the lateral part of the orbit with the
greatest diligence, particularly during orbitotemporal ac-
cesses. The atypically low placement of the vein must
surely expose it to pressure from fractures of the greater
wing of the sphenoid bone. This may cause an obstruc-
tion of venous blood flow within the orbit or a haematoma
as an additional symptom in the superior orbital fissure
syndrome (Zachariades et al., 1985).
What is also important is the changing position of
the ophthalmic artery in the posterior part of the orbit.
In a number of cases, the artery was placed not infe-
rior to the optic nerve but laterally. Govsa et al.
(1999) also mention such cases. The measurements
of the superior orbital fissure indicate that it constitutes
a more or less triangular field 17.3 Â 20.8 Â 9.5 mm
(Govsa et al. 1999). The range of variations is how-
ever large and the SD is up to 20% of the mean
value. According to Morard’s et al. (1994) measure-
ments, the size of the superior orbital fissure is on
Fig. 6 e Fragment of human orbit. Left side, anterior view. Atypical low
position of the superior ophthalmic vein. (1) Optic nerve, (2) superior
branch of the oculomotor nerve, (3) levator palpebrae muscle, (4)
trochlear nerve, (5) medial branch of frontal nerve, (6) periorbita and
circle of Zinn, (7) lateral branch of frontal nerve and the lacrimal nerve,
(8) long ciliary nerves. (9) nasociliary nerve, (10) superior ophthalmic
vein, (11) abducent nerve, (12) opthalmic artery, (13) inferior branch of
the oculomotor nerve.
Fig. 7 e Types of arrangement of nerves and vessels within the orbital
apex. (1) Optic nerve, (2) superior branch of the oculomotor nerve, (3)
trochlear nerve, (4) frontal nerve, (5) lacrimal nerve, (6) superior
ophthalmic vein, (7) nasociliary nerve, (8) abducent nerve, (9) inferior
branch of the oculomotor nerve, (10) ophthalmic artery.
Fig. 8 e Patient in the day of discharge from hospital. (A) Lateralisation
of right eyeball in looking ahead and (B) immobilisation of the right
eyeball during to look upward and to the left.
350 Journal of Cranio-Maxillofacial Surgery

6. average 3 Â 22 mm in length. This indicates there may
exist extreme differences that did not occur in the re-
searched material. In our investigation the length of
the superior orbital fissure was between 11 and
21 mm. The maximum length of the fissure measured
in this research was on average 15.62 and is close to
the result of Govsa et al. (1999) which was 16.9. Sim-
ilarly, one can compare the results in Table 1, the dis-
tances between the optic nerve and the inferior rim of
the superior orbital fissure; the rim fairly adequately
represents the height of the superior orbital fissure. Ac-
cording to our measurements, this distance was
10.88 mm. According to Govsa et al. (1999), on the
other hand, it was 9.0 mm as the distance between
the superior and inferior edges of the superior orbital
fissure. Similar results were presented by Natori and
Rhoton (1995). Their measurement criterion was the
distance between the lateral edge of the superior orbital
fissure and the structures lying within. Their fissure
length measurements from the outermost points of
the fissure was 15.9 mm (SD, 3.7; range, 7.7e22.1)
(Natori and Rhoton, 1995).
However, the length of the superior orbital fissure
varies greatly when the shape of the fissure is taken
into account, but only regarding the division into types
‘‘a’’ and ‘‘b’’ (Table 2). Such an approach allows us to
single out the oval shape fissure with smooth and regular
outline which at times may resembles an egg or a rounded
isosceles triangle. These fissures are generally character-
ised by shorter length and a considerable width. The
width does not however compensate for the shortness
of the fissure. In consequence, the area of the type ‘‘b’’
fissure is significantly smaller than the area of the type
‘‘a’’ fissure. This fact has not been mentioned in the lit-
erature. This information seems to be important as it
allows the surgeon to anticipate the topography and to
know what distances should be considered intraopera-
tively, before a standard skull radiograph is performed.
It should be emphasised that the nerves which are most
closely connected to the optic nerve are the nasociliary
nerve and the superior branch of the oculomotor nerve.
Importantly, any careless operation in the proximity of
the optic nerve may lead to injury of those delicate nerve
branches. According to Govsa et al. (1999), the follow-
ing structures lie in the greatest proximity to each other:
the superior branch of the oculomotor nerve and the me-
dial rim of the fissure, the trochlear nerve and the supe-
rior rim, the abducens nerve and the inferior edge. Our
observations confirm that such a layout is also present
in the apex of the orbit. However, a common phenome-
non in this area of the orbit (contrary to the orbital fis-
sure) is the division of the inferior and sometimes
superior branch of the oculomotor nerve into the
branches to successive external eye muscles. The frontal
nerve and the nasociliary nerve can also produce such de-
rivative stems (Fig. 4e6). In this area, long ciliary nerves
and supraorbital nerve and the supratrochlear nerve
already can be noticed.
Fig. 9 e CT scans of patient on the day of trauma. Arrows show fractures of sphenoid and maxillary bones. (AeC) Greater wing of sphenoid bone and
(D) lateral wall of maxillary sinus.
Superior orbital fissure 351

7. CASE REPORT
Case history (no. 17332/07): a 31-year-old man was ad-
mitted to the Maxillofacial Surgery Ward of Radom Hos-
pital in 2007after a bicycle accident. On admission, the
patient was alert but he showed signs of concussion
including headache and vertigo. Physical examination re-
vealed numerous facial cuticle abrasions, right upper and
lower eyelid haematomas (Fig. 8). Bilateral orbital ec-
chymosis predominantly on the right, right subconjuncti-
val haemorrhage, right blepharoptosis, exophthalmia and
ophthalmoplegia with the slight abduction were also
present. The sensation of touch in the right frontal area
was disturbed. The CT scan (Figs. 9 and 10) revealed
presence of a small amount of intracranial gas in the
basal cisterns, frontal lobes, and on the brain convexity,
as well as focal haemorrhagic contusion in the postero-
basal part of the right frontal lobe. The other brain struc-
tures were normal. The ventricular system was still
centered, not widened. There was also extensive subcuta-
neous emphysema of the right face, right lower eyelid,
and both orbits, blood in both maxillary, sphenoid and
ethmoid sinuses. There was an oblique fracture cleft of
the right orbital roof and some infraorbitally, fractures
in squamas of both temporal bones and wings of the
sphenoid bones. The examination also revealed fracture
of the lateral wall of the right sphenoid sinus, commi-
nuted fracture of the right maxillary sinus walls with
slight intussusception of the anterior sinus wall. An out-
fractured angularly orientated large bone chip was seen
in the lateral wall of the right maxillary sinus. Fractures
of the frontal process of the right zygoma and arch,
and the posterior osseous nasal septum were also visible.
Ophthalmological consultation confirmed bilateral
ecchymoses, predominantly in the right eye, right
blepharoptosis and exophthalmia with the slight abduc-
tion and total right ophthalmoplegia. The left eye was
normal. Neurological examination confirmed irregularity
of the pupils R . L and right eye immobility. Based on
the physical examination and radiological findings the di-
agnose of superior orbital fissure syndrome and orbital
apex syndrome were established. Anti-oedema and
anti-inflammatory treatments were initiated. The patient
was offered surgery to which he did not consent. After
10 days he was discharged from the hospital in good con-
dition (with recommendation of periodic follow up).
CONCLUSIONS
1. The superior orbital fissure has two basic morpho-
logical types, which differ according to size parame-
ters as well as the location of the structures within
the fissure.
2. The superior ophthalmic vein sometimes is the element
within the orbital apex which is placed most inferiorly.
3. Cranio-maxillofacial surgeon in his everyday prac-
tice has to manage the most complex posttraumatic
lesions, including superior orbital fissure syndrome.
Thorough knowledge of anatomy with topographical
variants enables quick diagnosis as well as appropri-
ate treatment.
References
Bergin DJ: Anatomy of the eyelids, lacrimal system and orbit. In Mc
Cord CD, Tanenbaum M (Eds), Oculoplastic surgery. 2nd ed. New
York: Raven Press, 1987: 46e47
Bowerman JE: The superior orbital fissure syndrome complicating
fractures of the facial skeleton. Br J Oral Surg 7: 1e6, 1969
Cruz AA, dos Santos AC: Blindness after Le Fort I osteotomy:
a possible complication associated with pterygomaxillary
separation. J Craniomaxillofac Surg 34: 210e216, 2006
Ettl A, Kramer J, Daxer A, Koornneef L: High resolution magnetic
resonance imaging of neurovascular orbital anatomy.
Ophthalmology 104: 869e877, 1997
Ettl A, Zwrtek K, Daxer A, Salomonowitz E: Anatomy of the orbital
apex and cavernous sinus on high-resolution magnetic resonance
images. Surv Ophthalmol 44: 303e323, 2000
Fauci AS, Haynes BF, Katz P, Wolff SM: Wegener’s granulomatosis:
prospective clinical and therapeutic experience with 85 patients for
21 years. Ann Intern Med 98: 76e85, 1983
Ferguson JW: An unusual skull fracture. Br J Oral Surg 12: 244e245,
1974
Ghobrial W, Amstutz S, Mathog RH: Fractures of the sphenoid bone.
Head Neck Surg 8: 447e455, 1986
Govsa F, Kayalioglu G, Erturk M, Ozgur T: The superior orbital fissure
and its contents. Surg Radiol Anat 21: 181e185, 1999
Hedstrom J, Parsons J, Maloney PL, Doku HC: Superior orbital fissure
syndrome. Report of case. J Oral Surg 32: 198e201, 1974
Kornblum K, Kennedy GR: Sphenoidal fissure: anatomical,
roentgenological and clinical study. Am J Roentgenol
Radiother 47: 845e858, 1942
Lang J: Lanz/Wachsmuth Praktische Anatomie. Kopf: Gehirn- und
Augenscha¨del. Jena: Springer Verlag, 1979
Miller NR. Walsh and Hot’s clinical neuroophthalmology, vol. 2.
Baltimore: Williams and Wilkins, 1985. 672e673
Fig. 10 e 3-D reconstruction of CT scans. (A) Antero-lateral view: (1)
fractures of zygomatic bone, (2) destruction of orbital roof, (3) bony
fragment in lateral part of superior orbital fissure. (B) Lateral view: (1)
fractures of zygomatic bone, (2) destruction of lateral wall of orbit
(greater wing of sphenoid bone).
352 Journal of Cranio-Maxillofacial Surgery

8. Morard M, Tcherekayev V, de Tribolet N: The superior orbital
fissure: a microanatomical study. Neurosurgery 35: 1087e1093,
1994
Nagasao T, Hikosaka M, Morotomi T, Nagasao M, Ogawa K,
Nakajima Y: Analysis of the orbital floor morphology.
J Craniomaxillofac Surg 35: 112e119, 2007
Natori Y, Rhoton Jr AL: Transcranial approach to the orbit:
microsurgical anatomy. J Neurosurg 81: 78e86, 1994
Natori Y, Rhoton Jr AL: Microsurgical anatomy of the superior orbital
fissure. Neurosurgery 36: 762e775, 1995
Pogrel MA: The superior orbital fissure syndrome: report of case.
J Oral Surg 38: 215e216, 1980
Shapiro R, Janzen AH: The normal skull: a Roentgen study. New
York: P.B. Hoeber Inc, 1960
Shapiro R, Robinson F: Alterations of the sphenoidal fissure
produced by local and systemic processes. J Anat 151: 255e257,
1967
Sharma PK, Malhotra VK, Tewari SP: Variations in the shape of the
superior orbital fissure. Anat Anz 165: 55e56, 1988
Sieverink NP, van der Wal HG: Superior orbital fissure syndrome in
a 7-year-old boy. Int J Oral Surg 9: 216e220, 1980
Ucerler H, Govsa F: Asterion as a surgical landmark for lateral
cranial base approaches. J Craniomaxillofac Surg 34: 415e420,
2006
Williams P, Bannister L: Gray’s anatomy. 38th ed. Edinburgh:
Churchill Livingstone, 1995. p. 555, 560, 571
Zachariades N, Vairaktaris E, Papavassiliou D, Papademetriou I,
Mezitis M, Triantafyllou D: The superior orbital fissure syndrome.
J Maxillofac Surg 13: 125e128, 1985
Dr. Jaros1aw WYSOCKI
Institute of Physiology and Pathology of Hearing
Zgrupowania AK Kampinos Str. 1, 01-943 Warsaw
Poland
Tel./Fax: +48 22 835 52 14
E-mail: j.wysocki@ifps.org.pl
Paper received 30 May 2007
Accepted 2 November 2007
Superior orbital fissure 353