Traumatic superior orbital fissure syndrome: current management

Abstract

Traumatic superior orbital fissure syndrome is an uncommon complication of craniomaxillofacial trauma with an incidence of less than 1%. The syndrome is characterized by ophthalmoplegia, ptosis, proptosis of eye, dilation and fixation of the pupil, and anesthesia of the upper eyelid and forehead. This article describes a detailed anatomy of the superior orbital fissure as it related to pathophysiology and clinical findings. Etiology and diagnosis are established after detailed physical and radiographic examination. On the basis of our clinical experience in the management of superior orbital fissure syndrome and from the data reported previously in the literature, an algorithm for treatment of traumatic superior orbital fissure syndrome including use of steroid, surgical decompression of superior orbital fissure, and reduction of concomitant facial fracture is presented and its rationale discussed.

Keywords: Superior orbital fissure; cranial nerve; optic nerve; orbital apex syndrome; steroid.

Figure 1

Frontal view of right internal orbit indicated optic foramen (arrow), superior orbital fissure (arrowhead), and inferior orbital fissure (line).

Figure 2

Contents of right superior orbital fissure.

Figure 3

Fractures of right temporal, sphenoid, and zygomatic bone are observed on the computed tomographic (CT) scan. The superior orbital fissure (arrow) becomes narrow and compressed by the sphenoid fracture. (A) Submental view on three-dimensional CT (3D-CT). (B) Coronal plane. (C) Horizontal plane.

Figure 4

A 32-year-old male with traumatic superior orbital fissure syndrome (SOFS) caused by carotid-cavernous sinus fistula (CCSF). (A) Patient presented the symptoms of SOFS along with orbit bruit. (B) Anterior-posterior right carotid angiogram showing a large CCSF. (C) One month after embolization, the eye movements are almost back to normal, except the abducens nerve.

Figure 5

A 12-year-old boy fell down from a height that resulted in right periorbital trauma and superior orbital fissure syndrome (SOFS). (A) Palpebral ptosis and ophthalmoplegia were present. (B) Computed tomography (CT) showed a retrobulbar hematoma around the orbital apex. (C) View of patient revealing the functional recovery of the right eye 4 months after steroid treatment.

Figure 6

Intraoperative view of left orbit after a combination of intracranial-extracranial approach. The depressed sphenoid bone is exposed (arrow).

Figure 7

Example of the depressed left sphenoid and temporal bone fractures causing superior orbital fissure syndrome (SOFF). (A) Preoperative axial view of computed tomographic (CT) scan. (B) Postoperative CT scan demonstrating adequate decompression at the superior orbital fissure.

Figure 8

Algorithm for management of traumatic superior orbital fissure syndrome.