PMC6028159_01
Computed tomography with contrast. Soft-tissue density, with erosion of the left medial orbital wall and loss of the fat plane between the medial orbital wall and the medial rectus muscle (white arrow and bracket).
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The last computerized tomography (CT) before the operation at a different facility documented erosion of the left medial orbital wall, with loss of the fat plane separating the wall from the medial rectus, and again identified a soft-tissue density in the medial orbit (Fig. 1).
T1-weighted magnetic resonance imaging with contrast, fat saturation sequence. (A) T1 fat saturation with contrast; dehiscence of the left lamina papyracea (gray arrow and bracket); enlargement of medial left medial rectus along the entire length of muscle (white arrow). (B) Thickening of the left medial orbital wall, obscuring the medial rectus.
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Magnetic resonance imaging after the procedure revealed dehiscence of the left lamina papyracea, enlargement of the ipsilateral medial rectus, thickening of nasal mucosa along the medial orbital wall, and a lesion of the left sphenoid sinus (Fig. 2).
Left nasal endoscopy. (A) Crusting of the left medial orbital wall; the opening to the sphenoid sinus is visible at the bottom left of the image (arrow); (B) Purulent drainage can be seen coming from the medial orbital wall (arrow); (C) Irritation after crust removal; (D) Purulent drainage sampled for culture.
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Nasal endoscopy demonstrated crusting and a bulging of the medial orbital wall, with purulent discharge into the nasal cavity (Fig. 3).
Extraocular muscle function testing, showing a normal right eye; the left eye shows restriction on abduction, adduction, and upward gaze; no abnormality on downward gaze was observed. The ratings are based on 9-point scale, from +4 to :4: zero represents normal movement; negative scores indicate limitations in movement, in which :1 is a 25% deficit, :2 is a 50% deficit, :3 is a 75% deficit, and :4 represents no movement; and positive scores denote movement beyond normal, in which +1 is a 25% increase, +2 is a 50% increase, +3 is a 75% increase and +4 is a 100% increase (from Ref. 30).
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Downward gaze was intact (Fig. 4).