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| CASE REPORT |
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| Year : 2022 | Volume
: 17
| Issue : 3 | Page : 734-736 |
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Steroids in the management of superior orbital fissure syndrome
Padmakar Sudhakar Baviskar, Srivalli Natarajan, Pradeep Pandurang Vathare, Chinmay Vasant Rao, Ruchita Arun Balkawade, Saloni Bharat Shah, Prachi Manoj Goyal
Department of Oral and Maxillofacial Surgery, Mahatma Gandhi Missions Dental College and Hospital, Navi Mumbai, Maharashtra, India
| Date of Submission | 13-Mar-2020 |
| Date of Decision | 01-Dec-2020 |
| Date of Acceptance | 08-Apr-2021 |
| Date of Web Publication | 2-Nov-2022 |
Correspondence Address:
Dr. Padmakar Sudhakar Baviskar
Department of Oral and Maxillofacial Surgery, 2nd Floor, Mahatma Gandhi Missions Dental College and Hospital, Sector 1, Kamothe, Navi Mumbai - 410 209, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jdmimsu.jdmimsu_65_20
Superior orbital fissure syndrome (SOFS) presents as complex impaired function of multiple cranial nerves with unique signs and symptoms. Traumatic etiology is seen in cases of trauma to the deep orbit with associated craniofacial fractures. Being a rare presentation to the oral and maxillofacial surgeon, a sound knowledge of this condition renders an effective diagnosis and prompt initiation of treatment necessary. Current literature evidence on management of this entity is low but highly debated. The authors present a case report of traumatic SOFS of an otherwise systemically healthy patient with detailed diagnostic evaluation and a close follow-up. A combination therapy of high then low-dose corticosteroids was initiated for the patient who demonstrated a rapid as well as complete recovery in 12 weeks. The authors conclude that steroid therapy for management has significantly reduced recovery time and should be considered over observational line of management.
Keywords: Corticosteroids, mydriasis, ophthalmoplegia, ptosis, superior orbital fissure syndrome
How to cite this article:
Baviskar PS, Natarajan S, Vathare PP, Rao CV, Balkawade RA, Shah SB, Goyal PM. Steroids in the management of superior orbital fissure syndrome. J Datta Meghe Inst Med Sci Univ 2022;17:734-6 |
| Introduction | |  |
Superior orbital fissure syndrome (SOFS) presents as complex impaired function of cranial nerves III, IV, V, and VI. The entity was first described by Duvigneaud[1] in 1896 as sphenoidal fissure syndrome. The most common causes are trauma, tumor, and inflammation. A traumatic origin was first described by Hirschfeld[2] in 1858. Lakke[3] defined the complete syndrome in 1962. Zachariades et al.[4] described the incidence of traumatic SOFS to be 1 (0.8%) in every 130 cases of facial fractures. Chen et al.[5] in 2010 described incidence as 0.3% with 33 of the total 11,284 patients of craniofacial fractures. Clinically, SOFS presents with signs and symptoms, categorized by Rai and Rattan[6] in 2012 are mentioned in [Table 1] with correlation to this case report. | Table 1: Clinical signs and symptoms of superior orbital fissure syndrome and correlation in the reported patient
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Traumatic SOFS is associated with trauma to the deep orbit due to associated craniofacial, zygomatic, and orbital fractures.[7],[8] SOFS is a rare presentation to oral and maxillofacial surgeons, however it has unique signs and symptoms which can be objectively identified with a sound knowledge of the disease entity. Prompt diagnosis and evaluation by an ophthalmologist is necessary to initiate necessary treatment and deciding the required duration with subsequent follow-up to the therapy.
Hereby, the authors report a presentation of SOFS managed with steroids with follow-up till complete recovery.
| Case Report | | |
A 19-year-old male patient was referred from the department of ophthalmology for opinion regarding orbital walls fracture evident in computed tomography (CT). The patient presented with a history of trauma to the left orbit 1 week ago. The patient had a history of fall from a height of 10 feet. The patient was systemically stable and did not have any other comorbidities.
On examination, the patient presented with left upper eyelid ptosis [Figure 1]. Initial evaluation by the ophthalmologist revealed vision 6/9, normal color vision, presence of corneal reflex, normal fundus examination, but restriction of visual field in all gazes. Left eye mydriasis was noted [Figure 2]. The left pupil was very sluggishly reactive to light with absence of direct and accommodation reflex. Left oculomotor (CN III), trochlear (CN IV) and abducent (CN VI) nerve palsy presenting as ophthalmoplegia of superior rectus, superior oblique, medial and lateral rectus muscles with restricted extraocular motility in superior, lateral and medial gaze was also noted [Video Clip 1]. There was no restriction in downward gaze. No enophthalmos or proptosis was evident. There was no associated complaint of decreased lacrimation. The patient also complained of paresthesia of upper eyelid, median part of supraorbital region, and forehead on the left side. | Figure 2: Demonstration of left pupillary mydriasis with absence of accommodation reflex
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CT revealed fracture of left lesser wing of sphenoid bone, roof of the orbit, and left lateral wall of the orbit fracture [Figure 3]. Magnetic resonance imaging of the orbits revealed inflammation in the superior aspect of the left posterior orbit in T2 and fluid-attenuated inversion recovery intensities. Perimetry revealed reduced visual field in the left lateral superior gaze. Visual-evoked potential was normal ruling out traumatic optic neuropathy. Forced duction test done under local anesthesia was normal and without any restriction in motility of the globe which ruled out entrapment of muscle and orbital contents in the fracture. Hence, a diagnosis of traumatic SOFS was made. | Figure 3: Axial computed tomography scan image showing fracture of roof of the orbit and lesser wing of Sphenoid bone adjoining the superior orbital fissure
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Because the patient did not have any obvious displaced fracture, muscle entrapment, diplopia or comminution of bony walls with need for immediate attention, no treatment was initiated for orbital fractures. A decision for conservative and medicinal line of management with daily observation was made in agreement with the ophthalmologist for treatment of the SOFS.
For the medicinal management, the patient was initially started on high-dose injection methyl prednisolone 1 g intravenously (IV) thrice a day (TDS) for 7 days. At the end of 1 week of IV steroid therapy, the patient showed gradual but significant improvement with regard to ptosis and mydriasis but restriction in lateral and upward gaze was persistent [Video Clip 2].
Hence, steroid therapy was continued with oral methyl prednisolone 1 mg/kg of body weight, effective dose of 50 mg TDS. Tapering of oral dose was done by 10 mg every 3 days. Effectively, the patient received IV steroids for 1 week and oral steroids for 2 weeks.
Following completion of steroid therapy, the patient was prescribed methyl cobalamin (1500 mcg) + pregabalin (75 mg) for forehead paresthesia OD for 1 month. The patient showed noteworthy and complete recovery as compared to normal side in terms of ptosis [Figure 4], ophthalmoplegia, and paresthesia of the forehead extraocular muscle function at the 12th-week follow-up [Video Clip 3]. | Figure 4: Follow-up after 12 weeks demonstrating significant resolution of ptosis
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| Conclusion | | |
The differential diagnosis for SOFS is orbital apex syndrome, a term coined by Kjaer,[9] ruled out by additional involvement of optic nerve. Other differential diagnoses include anterior, middle, and posterior cavernous sinus syndrome with involvement of trigeminal nerve, generally associated with intracranial lesions.[10]
Treatment of SOFS has been debated and has a low but strong current literature evidence. Many clinicians prefer observation over medical or surgical intervention. Conservative treatment with observation alone has been proposed because complete or partial spontaneous recovery of the motor and sensory functions usually occurs when the syndrome results from trauma.[11]
With just observation, recovery can last up to 6 months, but complete return to function is questionable. The usual medical line of management of SOFS is mega dose IV corticosteroid therapy.[12] Surgical intervention for SOFS has also been advocated in bony compression of contents of the fissure.[5] It regularly involves procedures to decompress the structures and edema of the posterior orbit and the superior orbital fissure.
However, the hazard of further hemorrhage or injury to nerve and operative difficulties are the major drawback of surgical exploration.[13] Surgical intervention also may not be amenable in centers lacking advanced surgical equipment and intraoperative imaging. Mortada[14] recommended evacuation of hematoma in the orbital apex if medical treatment is unsuccessful even after 4 months.
Chen et al.[15] in 2010 reported 19 cases treated with conservative management with high-dose steroid alone with complete recovery in eight patients. Chen et al.[5] in 2010 reported 33 cases of traumatic etiology, with 24%–40% showing complete recovery with steroids, 21.4% recovery in cases without steroids. In addition, abducent nerve showed the best recovery in terms of the function of lateral rectus muscle.
From this case report, the authors would like to conclude that steroid therapy for the management of SOFS is of greater benefit to the patient due to significantly reduced recovery time. As supported by literature, mega dose steroid therapy for management of SOFS should be considered over observation in an otherwise systemically healthy patient.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Duvigneaud AR. Effusion of blood in the cavernous sinus of the side diagnostic left for life. Arch d'ophthalmol Paris 1896;16:746-60.  |
| 2. | Hirschfeld D. Effusion of blood in cavernous sinus of left side diagnosed during life. C R Soc Biol 1858:138. |
| 3. | Lakke JP. Superior orbital fissure syndrome. Report of a case caused by local pachymeningitis. Arch Neurol 1962;7:289-300. |
| 4. | Zachariades N, Vairaktaris E, Papavassiliou D, Papademetriou I, Mezitis M, Triantafyllou D. The superior orbital fissure syndrome. J Maxillofac Surg 1985;13:125-8. |
| 5. | Chen CT, Wang TY, Tsay PK, Huang F, Lai JP, Chen YR. Traumatic superior orbital fissure syndrome: Assessment of cranial nerve recovery in 33 cases. Plast Reconstr Surg 2010;126:205-12. |
| 6. | Rai S, Rattan V. Traumatic superior orbital fissure syndrome: Review of literature and report of three cases. Natl J Maxillofac Surg 2012;3:222. [ PUBMED] [Full text] |
| 7. | Banks P. The superior orbital fissure syndrome. Oral Surg Oral Med Oral Pathol 1967;24:455-8. |
| 8. | Bowerman JE. The superior orbital fissure syndrome complicating fractures of the facial skeleton. Br J Oral Surg 1969;7:1-6. |
| 9. | Kjaer I. A case of orbital apex syndrome in collateral pansinusitis. Acta Ophthalmol 1945;23:357-66. |
| 10. | Hallpike JF. Superior orbital fissure syndrome. Some clinical and radiological observations. J Neurol Neurosurg Psychiatry 1973;36:486-90. |
| 11. | Zachariades N. The superior orbital fissure syndrome. Review of the literature and report of a case. Oral Surg Oral Med Oral Pathol 1982;53:237-40. |
| 12. | Acartürk S, Seküçoğlu T, Kesiktäs E. Mega dose corticosteroid treatment for traumatic superior orbital fissure and orbital apex syndromes. Ann Plast Surg 2004;53:60-4. |
| 13. | Campiglio GL, Signorini M, Candiani P. Superior orbital fissure syndrome complicating zygomatic fractures: Pathogenesis and report of a case case report. Scand J Plast Reconstr Surg Hand Surg 1995;29:69-72. |
| 14. | Mortada A. Superior orbital fissure syndrome of uncertain aetiology* report of ten cases. Br J Ophthalmol 1961;45:662-71. |
| 15. | Chen CT, Chen YR. Traumatic superior orbital fissure syndrome: Curr Manag Craniomaxillofac Trauma Reconstr 2010;3:9-16. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1]
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