Apex Orbital Syndrome Following Traumatic Orbital Injury: Clinical And Therapeutic Approach In The Context Of Cataract Surgery And Corneal Sensitivity

The aim of this report is to describe the clinical presentation, diagnostic procedures, and treatment of a patient with apex orbital syndrome following traumatic orbital injury, which led to optic neuropathy and total ophthalmoplegia. Additionally, the report explores the challenges of performing cataract surgery in this patient, particularly considering the permanent mydriasis due to oculomotor nerve paresis and corneal desensitization caused by trigeminal nerve paresis.

UHC Zagreb, Croatia

A 48-year-old male patient presented to the Emergency Department with significant traumatic injuries sustained from a fall, resulting in a penetrating injury to the right infraorbital region. Immediately after the trauma, the patient experienced ptosis of the right eyelid, vision loss in the affected eye, and independently removed the foreign body. The patient underwent clinical examination, otorhinolaryngological assessment, CT, and MRI scans. The clinical examination included an ophthalmological assessment, which revealed traumatic ophthalmoplegia, ptosis, anisocoria, and mydriasis. CT and MRI scans were performed to confirm the diagnosis of apex orbital syndrome and to assess the extent of the injury.

MRI revealed thickening of the medial rectus muscle, intraorbital edema, and minor linear T2 hyperintensity around the right optic nerve, suggesting perineural fluid. Ophthalmological examination showed traumatic ophthalmoplegia, ptosis, anisocoria, and permanent mydriasis. Fundoscopy demonstrated slightly elevated nasal papilledema and hypertensive changes in retinal blood vessels.

Given the patient's unique presentation, including permanent mydriasis and corneal desensitization due to trigeminal nerve paresis, special considerations were made regarding cataract surgery. These challenges include the inability to achieve proper pupil dilation and the increased risk of corneal complications due to reduced sensitivity.

Apex orbital syndrome, involving optic neuropathy and ophthalmoplegia due to traumatic injury, is a rare but serious condition that requires a comprehensive diagnostic approach. Treatment typically involves corticosteroid therapy, antibiotic administration, and regular ophthalmological follow-up. For patients with additional complications such as permanent mydriasis and corneal desensitization, cataract surgery must be carefully planned and managed. Preoperative measures, such as optimizing the ocular surface and considering pupil expansion techniques, are essential. Postoperative care is critical, particularly for managing corneal healing and reducing the risk of complications.