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| CASE REPORT |
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| Year : 1994 | Volume
: 42
| Issue : 4 | Page : 213-214 |
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Orbital apex syndrome : A rare complication of septorhinoplasty
SG Jaison, SM Bhatty, SK Chopra, V Satija
Department of Ophthalmology, Christian Medical College & Hospital, Ludhiana, India
Correspondence Address:
S G Jaison
Department of Ophthalmology, Christian Medical College & Hospital, Ludhiana 141008
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 10577002 
How to cite this article:
Jaison S G, Bhatty S M, Chopra S K, Satija V. Orbital apex syndrome : A rare complication of septorhinoplasty. Indian J Ophthalmol 1994;42:213-4 |
Orbital apex syndrome consists of involvement of the second, third, fourth, sixth and ophthalmic division of the fifth cranial nerves as they pass through the optic foramen and superior orbital fissure at the apex of the orbit. This is commonly due to space occupying and inflammatory lesions or trauma involving the apex of the orbit. [1]
We report a case of orbital apex syndrome following septorhinoplasty. To the best of our knowledge, this complication has not been reported in the literature.
| Case report | |  |
A 50-year-old male presented with a history of a road traffic accident resulting in closed head injury and multiple fractures of the craniofacial bones. Following the trauma he developed convergent squint in the right eye and binocular horizontal diplopia.
One year following the trauma he underwent septorhinoplasty under general anaesthesia for gross traumatic deviated nasal septum towards the right, occluding the right nasal passage.
Surgical Procedure
The left nasal cavity was exposed with nasal speculum. Two percent xylocaine with adrenaline (1:200000) was used to infiltrate and raise the mucoperichondrium and mucoperiosteum of the nasal septum. Incision was given at the caudal end of the septum on the left side. With a perichondrial elevator, mucoperichondrium and mucoperiosteum was elevated. Pressure was applied at the bony cartilaginous junction to deflect the cartilaginous septum. Through the gap thus produced between the bony and cartilaginous septum, the elevator was introduced and the mucoperiosteum of the right side was also elevated, exposing the perpendicular plate of ethmoid and vomer bones. These bones were partially removed with Luc's forceps. Antibiotic-soaked glove packs were used to pack both nasal cavities.
At the end of the surgery, the patient was found to have marked proptosis and subconjunctival haemorrhage of the right eye. There was also periorbital ecchymosis on the right side. In the immediate postoperative period there was ptosis of the upper lid and total loss of vision in the right eye.
Examination a few days later revealed a visual acuity of no light perception in the right eye and 6/6 in the left eye. The right eye had subconjunctival haemorrhage and ecchymosis in the periorbital region. There was complete ptosis of the right upper lid with no levator palpebrae superioris action [Figure - 1]. The right eyeball was fifteen degrees hypoesotropic. Ocular movements were restricted in all the cardinal directions of gaze [Figure - 2]. Pupil was dilated (5 mm), with absence of direct and consensual reactions to light. Corneal sensation and cutaneous sensation in the area of distribution of ophthalmic division of the fifth cranial nerve were absent on the right side.
On ophthalmoscopy, the optic disc appeared to be normal. Intraocular pressure was 16 mm of Hg in both eyes. Left eye had enophthalmos and irregular orbital margins due to the old fracture [Figure - 1].
CT scan of the orbits demonstrated fracture of the ethmoid bone in the medial wall of the right orbit into which right medial rectus muscle was incarcerated [Figure - 3].
There was no fracture in the superior orbital fissure or optic foramen region. The incarceration of the medial rectus muscle was confirmed by forced duction test. Examination at three months postseptorhinoplasty revealed gross pallor of the optic disc in the right eye. Previous ocular findings continued to persist.
| Discussion | | |
Blindness has rarely been a complication of surgical procedures in the orbit. It has been attributed to intraoperative or postoperative orbital haemorrhage, manipulation of the optic nerve, etc . [2] Visual loss following intranasal endoscopic surgery has also been reported . [3] Loss of vision following cosmetic blepheroplasty is also a documented tragedy. The mechanism of such an event may be related to occult orbital haemorrhage during lid manipulation or prolonged pressure on the globe due to the tight bandage in the postoperative period. [4]
The simple surgical procedure of septoplasty has been very rarely complicated by blindness due to central retinal artery spasm.[5] But to the best of our knowledge, orbital apex syndrome has not been reported in the literature as a complication of septorhinoplasty. Even though surgical procedure in itself was uneventful, undiagnosed fractured ethmoid bone into which medial rectus muscle was incarcerated resulted in severe orbital haemorrhage. As the fibrous tissue at the fracture site tends to be highly vascular, even minimal disturbance in this region at the time of surgery could have resulted in massive orbital haemorrhage, causing severe pressure on the cranial nerves in the orbital apex.
Immediate diagnosis and timely decompressive procedure probably could have saved the patient from this tragedy. Patients who have sustained fracture of the cranofacial bones should be subjected to thorough examination and necessary investigations prior to contemplating on any surgical procedure in and around the orbit and any such surgical procedure should be undertaken with great caution.
| References | | |
| 1. | Vaughan D, Asbury T. Neuro-ophthalmology. In General Ophthalmolgy. 9th ed. Los Altos, California, Lange Medical Publications, 1980; pp 213-245.  |
| 2. | Long JC, Ellis PP. Total unilateral visual loss following orbital surgery. Am J Ophthalmol 71:218, 1971 |
| 3. | Stankiewicz J. Blindness and intranasal endoscopic ethmoidectomy - prevention and management. Otolaryngol Head and Neck Surg 101:320-329, 1989. |
| 4. | Moser MH, Dipirro E, McCoy FJ. Sudden blindness following blepheroplasty: Report of seven cases. Plast Reconstr Surg 51:364, 1973. |
| 5. | Rettinger G, Christ P, Meythaler FH. Blindness caused by central artery occlusion following nasal septum correction. H NO 38:105-109,1990. |
[Figure - 1], [Figure - 2], [Figure - 3]
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