Frozen overnight: Acute orbital apex syndrome caused by aspergillosis

Purpose to describe a rare case of orbital apex syndrome caused by aspergillosis with acute presentation. Case description retrospective case report of a 70-year-old man who developed unilateral ophthalmoplegia overnight. He was initially given the diagnosis of suspect Tolosa-Hunt syndrome, but biopsy of the involved tissue showed aspergillosis. Conclusion orbital apex syndrome caused by fungal disease is a life-threatening condition that should be promptly diagnosed and treated. It may present acutely and should not be misdiagnosed as Tolosa-Hunt syndrome. To our knowledge this is the first such case report in the English ophthalmic language Literature.

Anatomical step-by-step dissection of complex skull base approaches for trainees: Endoscopic endonasal approach to the orbit

Introduction: Although endonasal endoscopic approaches (EEA) to the orbit have been previously reported, a didactic resource for educating neurosurgery and otolaryngology trainees regarding the pertinent anatomy, techniques, and decision-making pearls is lacking. Methods: Six sides of three formalin-fixed, color latex-injected cadaveric specimens were dissected using 4-mm 0º and 30º rigid endoscopes, as well as standard endoscopic equipment, and a high-speed surgical drill. The anatomical dissection was documented in stepwise 3-D endoscopic images. Following dissection, representative case applications were reviewed. Results: EEA to the orbit provides excellent access to the medial and inferior orbital regions. Key steps include positioning and preoperative considerations, middle turbinate medialization, uncinate process and ethmoid bulla removal, complete ethmoidectomy, sphenoidotomy, maxillary antrostomy, lamina papyracea resection, orbital apex and optic canal decompression, orbital floor resection, periorbita opening, dissection of the extraconal fat, and final exposure of the orbit contents via the medial-inferior recti corridor. Conclusion: EEA to the orbit is challenging, in particular for trainees unfamiliar with nasal and paranasal sinus anatomy. Operatively oriented neuroanatomy dissections are crucial didactic resources in preparation for practical endonasal applications in the OR. This approach provides optimal exposure to the inferior and medial orbit to treat a wide variety of pathologies. We describe a comprehensive step-by-step curriculum directed to any audience willing to master this endoscopic skull base approach.

Infranuclear Eye Movement Disorders

Infranuclear motility disorders are such of the cranial nerves, the extraocular muscles or changes in the orbit but definitely peripheral to the nuclei of the cranial nerves. Characteristic are movement deficits, a compensatory head posture and the pattern of incomitancy. The secondary angle of deviation is usually larger than the primary. Combined pareses suggest a lesion in the cavernous sinus, orbital apex or a multilocular event. It is essential to rule out supranuclear disorders, especially if the motility deficit is atypical. For clarification, an individual risk assessment is recommended, paying particular attention to risk factors.

P.089 A report of a patient presenting with orbital apex syndrome secondary to NK cell lymphoma (nasal type)

Background: Orbital apex syndrome (OAS) can be caused by a broad range of disorders. There are several challenges present in the evaluation of these patients and in reaching a final diagnosis. We report the case of a 69-year-old male who presented with OAS that was determined to be secondary to a rare malignancy (NK cell lymphoma, nasal type). Methods: We analyze the pitfalls and diagnostic delays in this patient’s evaluation. Furthermore we propose a work up for undifferentiated cases of OAS. Results: To accurately diagnose the underlying cause of OAS, a direct biopsy should be obtained whenever possible. The appropriate imaging sequences should be arranged as lesions in this region can be easily missed. Adjunct tests include assessment in the serum and CSF for granulomatous and infectious diseases, along with chest imaging. As many causes are PET enhancing, PET CT is a useful modality for identifying sites for biopsy. Conclusions: OAS can provide a diagnostic challenge for clinicians, however a systematic approach can help determine the underlying etiology.

Atypical Optic Neuritis in an Immunocompetent Patient with Orbital

Aspergillosis infection in immunocompetent individuals is an uncommon entity. Non-specific presentation could delay in the diagnosis and management. We describe a case of orbital aspergillosis with cavernous sinus extension in a healthy lady. A 67-year-old lady presented with left eye decreased vision, preceded by non-specific headache for three weeks. Visual acuity deteriorated followed by ptosis and left ocular restrictions after corticosteroids therapy. Examination revealed poor left eye visual acuity with ptosis, anisocoria and total ophthalmoplegia. MRI orbit and brain demonstrated a heterogenous left orbital apex lesion extending to cavernous sinus. Transsphenoidal endoscopic biopsy revealed Aspergillus infection at the left retro-orbital space and the sphenoid sinus. Patient was treated with long duration of oral voriconazole. Ptosis and ophthalmoplegia resolved but left optic atrophy remained. In conclusion, orbital aspergillosis may carry a poor visual prognosis and intracranial spread does easily occur. Early treatment may lead to a better outcome in immunocompetent patients.