This document discusses orbital apex syndrome, which involves damage to cranial nerves II, III, IV, and VI and the ophthalmic branch of cranial nerve V. It describes the anatomy of the orbital apex including the optic foramen and superior orbital fissure. Common causes of orbital apex syndrome include tumors, infections, vascular abnormalities, trauma, and inflammation. The document outlines the clinical features, diagnostic workup, and management approaches for orbital apex syndrome depending on its underlying etiology.

1. Orbital Apex Syndrome
Author.... Dr Prithvi Raj
Co author... Dr Rohit khatri
J. l. N. Hospital and medical
College
Ajmer

2. Apex of Orbit
 Posterior most end of pyramid shaped orbit
 4 orbital walls converse Here at craniofacial junction
 There are 2 orifices is situated in the sphenoid bone
 Optic foramen
 Superior orbital fissure

3. Optic foramen
 Located within the lesser wing of sphenoid and form by two bony roots
that connect the laser wing to body of sphenoid
 The inferior root separate it from SOF and superior root from anterior
cranial fossa
 From anterior view, the entrance to the optic canal is the most superior
and medial structure in the Apex
 It Attends adult dimension by age of 3 years
 Vertically 6-6.5mm
 Horizontally 4.5-5mm
 >7mm Abnormal (gliomas,Meningiomas)
 It contains optic nerve and its meningeal covering, ophthalmic artery,
sympathetic nerves

4. SOF
 It is a bony cleft which Lies between lateral wall and the roof of the
orbit, bounded by greater and lesser wing of sphenoid
 Largest communication between orbit and middle cranial fossa
 Annulus of zin encircles the optic foramen and centre part of
superior orbital fissure dividing it into 3 part

5. Content of SOF, IOF & Optic Canal

6. Optic canal
 Optic canal passes posteriomedially and opens Into chiasmatic
groove
 The canal has an intimate relationship to the sphenoid sinus, pron to
damage in sphenoid fracture
 Optic nerve glioma or meningioma may lead to unilateral
enlargement of optic canal, seen on x ray

7. Inferior orbital fissure
 20mm bony defect lies between lateral wall and floor of the orbit
 Communicates orbit with the infratemporal fossa and
pterygopalatine fossa
 Bounded by
 Sphenoid
 Zygomatic
 Maxillary
 Palatine bones

8. Orbital Apex syndrome
 Involves damage to
 oculomotor nerve (III)
 Trochlear nerve (IV)
 Abducens nerve (VI)
 Ophthalmic branch of trigeminal nerve (V1)
 With optic nerve (II) dysfunction
 In SOF Syndrome -- optic nerve not involved
 Cavernous sinus syndrome (CSS) may include the feature of an OAS
with added involvement of
 Maxillary branch of trigeminal nerve (V2)
 Oculo-sympathetic fibres (periarterial sympathetic plexus)

9. Comparison

10. Anterior Syndromes related to pathological involvement of CS

11. Orbital Apex relation with
Cavernous sinous

12. Etiology of OAS
 Vascular cause
 Carotid cavernous aneurysm
 Carotid cavernous fistula
 Cavernous sinus thrombosis
 Sickle cell anaemia
 Inflammatory (OID)
 Thyroid ophthalmopathy
 Sarcoidosis
 Wegener’s granulomatosis
 Giant cell arteritis
 Orbital inflammatory
pseudotumor
 Tolosa hunt syndrome

13.  Infectious
 Fungi: Aspergillosis, Mucormycosis
 Bacterial: streptococcus spp, staphylococcus Spp, Actinomyces spp,
gram negative bacillus, anaerobes, mycobacterium tuberculosis
 Spirochetes: treponema pallidum
 Viruses: herpes zoster
 Traumatic
 Penetrating injury
 Non penetrating injury
 Orbital Apex fracture
 Retained foreign bodies

14.  Neoplastic
 Head and neck tumors: nasopharyngeal carcinoma, adenoid cystic
carcinoma, squamous cell carcinoma
 Neural tumors: neurofibroma meningioma ciliary neurinoma,
schwannoma, gliomas
 Metastatic lesions: of lung, breast, renal cell, malignant melanoma
 Hematologic: burkitt lymphoma, non hodgkin lymphoma, leukaemia
 Perineural invasion of cutaneous malignancy
 Iatrogenic
 Sinonasal surgery
 Orbital/facial surgery

15.  The incidence of etiological factor----
 Tumours 30%
 Iatrogenic traumatic etiology 35%
 Inflammatory etiology 23%
 Vascular , infections and other 12%

16. Features of AOS
 Ophthalmoplegia,
 Vision loss
 Upper eyelid ptosis,
 Non reactive dilated people
 Anaesthesia over ipsilateral forehead,
 Loss of corneal sensation,
 Orbital and periorbital pain
 Axial proptosis,
 Ocular deviation
 Neurotrophic keratopathy

17. History taking
 H/o blunt orbital trauma
 History of visual loss- weather at the time of injury or subsequently,
progressive decrease in vision.
 H/o diplopia- binocular misalignment, diplopia will be worse in the field
of gaze of the paretic muscles
 H/o Ptosis
 Past ophthalmic history- spectacles, decreased vision, amblyopia,
strabismus and previous ocular surgery
 History of sensory disturbance in distribution of V1 and V2
 H/o systemic disease – DM/HTN/TB/Thyroid
 H/o previous ocular Sx, PNS surgery
 H/o TIA or occlusive pathology

18. Examination
 Orbital inspection: ecchymosis, edema and proptosis
 Globe position: Hertel’s exophthalmometry –proptosis measurement.
 Palpation: retropulsion , orbital trill/pulsation, any swelling and mass
 Ocular motility defects : voluntory movement, forced duction and
force generation examination
 Conjuctiva, corneal, scleral examination
 Visual acuity: Including pinhole vision, colour vision and visual fields
 Pupil response: RAPD/TAPD/EPD(TONIC PUPIL)
 IOP

19.  Anterior segment examination including corneal injury, hyphema,
iridodialysis, lens dislocation, pupillary reaction
 Posterior segment including retinal Commotio, retinal detachment,
choroidal rupture and scleral rupture , optic nerve head perfusion,
disc swelling and peripapillary hemorrhages

20. Imaging
 Xray : Orbit with PNS
 PA view for SOF – Caldwell view
 Oblique view for Optic foramen—Rhese view
 PNS and Floor of orbit—water’s view
 CT scanning: usefull in suspected fractures, mass lesion, hematoma

21.  MRI:
 Any malignancy, mass effect, small hematomas, tiny infarct in brain,
Vascular pathology, and infective conditions
 Fat suppression techniques are useful for retrobulbar optic neuritis,
Intraorbital meningioma, fungal infiltration, infective and infiltrative
pathology,
 MRI Angiography: Gold standard for intracranial vascular diseases, such
as intracranial aneurysm or shunts, And involvement of carotid artery
and cavernous sinus

22. Biopsy
 Biopsy taken from involve part like PNS, periorbital tissue, after
decompression Sx (FESS, Decker’s procedure)
 To find out neoplasia, infiltrative Disease, fungal invasion
 After biopsy culture and sensitivity test are done for infective
condition. (KOH mount, gram stating, bacterial and fungal culture)

23. Blood investigation

24.  Management of OAS is aimed at the underlying cause.
 Primary management – includes observation, surgical biopsy and
corticosteroids ( if cause can not be determined.)
 If visual loss and ophthalmoplegia progresses repeat neuroimaging
and a biopsy.
 Neurosurgical, neurophysician, internal medicine, otolaryngologic
and radiological consultation must be required.
 Following traumatic and iatrogenic operative injury , corticosteroids
and surgical intervention will be considered.

26. Etiology Disease Management
Orbital Inflammatory
disease
Sarcoidosis NSAIDS, steroids,
immunosuppresent,
surgical debulking
Wegner’s granulomatosis
Giant cell artritis
Tolosa hunt syndrome
Steroids and
immunosuppresent
TAO Antithyroid drugs and
surgical management
Infectious etiology Mucormycosis
aspergillosis
Iv amphotericin B and
local excision of necrotic
tissue
Bacterial Iv antibiotic and
anticoagulents
HZO Acyclovir and
corticosteroids

27. Tumors etiology Nasopharyngeal cancer,
lyphoma, meningioma,
Surgical intervention with
radiotherapy and
chemotherapy
Iatrogenic and tramatic
etiology
Apex orbital fractures,
sphenoid fractures
Corticosteroids and
surgical interventions.

28. Thank you