Further Outpatient Care
Long-term follow-up care is required in those with optic neuropathy, continued diplopia, and disturbance of trigeminal nerve.
Visual recovery with traumatic optic neuropathy may take several months. More formal visual assessment may be undertaken in the outpatient setting (eg, perimetry, electrophysiology).
Diplopia, with extraocular muscle paresis, also may take many months to improve maximally. Having stable strabismus for several months prior to strabismus surgery is advocated.
The presence of an anesthetic cornea may lead to a neurotrophic keratopathy, especially if associated with a dry eye (in elderly patients and with lacrimal gland trauma or deinnervation), and/or facial nerve palsy (eg, skull base fractures of the temporal bone).
Further Inpatient Care
Continued neurologic observations and serial visual acuity assessments are appropriate with an orbital apex fracture. Progressive loss of vision may be seen with a compressive neuropathy of optic nerve sheath hematoma, bony impingement, or orbital hemorrhage.
Associated complications of trauma include CSF leak and carotid-cavernous fistula may not present early in the course of care and should be watched for. Diabetes insipidus presented in one series.
Complications
In Unger's 1984 review of 23 orbital apex fractures (in 17 patients), documented complications included optic nerve damage (n = 3), SOF syndrome (n = 6), orbital apex syndrome (n = 2); in this series, it was not possible to satisfactorily examine 13 orbits because of soft tissue injury, globe rupture, or altered level of consciousness. [6]
In Unger's 1990 review of 78 patients with sphenoid fractures, 21 patients had documented complications of the fracture. These included optic nerve injury with decrease in vision (n = 5), extraocular muscle palsy (n = 3), internal carotid artery injury (n = 5), CSF leak (n = 7), and diabetes insipidus (n = 1). [3]
In Ghobrial's 1986 series of 17 sphenoid fractures, 3 patients had traumatic optic neuropathy, and 3 had a SOF syndrome. [2]
Complications of surgical decompression of the optic canal include direct or collateral damage to the optic nerve axons and vascular supply. When orbital apex surgery is contemplated, the potential for iatrogenic damage to other apex structures and intracranial structures must be balanced against the potential for a functional improvement in any individual patient.
Complications of medical treatment are those of high-dose steroids, including hyperglycemia, hypokalemia, osteonecrosis, gastric ulceration, acute pancreatitis, and opportunistic infections. See Medication.
Prognosis
With improved imaging of trauma patients, it is apparent that many patients with orbital apex fractures do not present with neurovascular complications. However, many patients do have significant associated craniofacial trauma, with resultant mortality and morbidity.
In nonpenetrating trauma, significant improvement in extraocular muscle paresis may occur, because the injury is presumably a neuropraxia to some degree. The prognosis in indirect traumatic optic neuropathy is reported in the International Optic Nerve Trauma Study, where many patients improved. [21] The initial visual acuity was a strong predictor of the final visual acuity.
Patient Education
For excellent patient education resources, visit eMedicineHealth's Eye and Vision Center. Also, see eMedicineHealth's patient education article Black Eye.
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Axial CT scan exhibiting a left apex fracture through the optic canal. Note associated lateral wall and medial wall fractures. This patient also required a craniotomy for a subdural hematoma.
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Coronal reconstruction of CT scan of left orbital apex fracture through the optic canal. This patient presented with an orbital apex syndrome. Note the displaced bone fragment from the lateral wall of the sphenoid sinus.
