PMC3225456_01
Photographs of eye positions in all directions, and the pupils and face of our patient before treatment. (A) Photographs of eye positions in all directions. Complete ophthalmoplegia and ptosis can be seen on the right side. (B) Photographs of pupils under standard room lighting. Anisocoria can be seen and the right pupil is dilated. The light reflex is absent. (C) Photograph of the face. Mixed vesicular and crusted eruptions can be seen along the first division of the trigeminal nerve. Complete ptosis is present in the right eye. (D) Goldmann kinetic perimetry. Slight constriction of the visual field was detected in the right eye.
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On day 17 of the hospital day, she developed ptosis and total ophthalmoplegia in the right eye (Figure 1A). The pupillary diameters were 4.5 mm OD and 2.5 mm OS, and the light reflex in the right eye was absent (Figure 1B). Goldmann kinetic perimetry showed a slight constriction of the central visual field in the right eye (Figure 1D).
Enhanced fat-suppressed T1-weighted magnetic resonance images. (A and B) before steroid therapy. (C and D) after intravenous prednisolone. (A and C) are horizontal sections. (B and D) rare coronal sections. Enhancement of the optic nerve sheath and orbital apex can be seen before treatment (arrows).
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Enhanced T1-weighted MRI showed enhancement of the optic nerve and orbital apex (Figure 2A and B). Repeated MRI showed a decrease in enhancement of the right optic nerve and the tissues around the orbital apex (Figure 2C and D).
Time course of ocular symptoms and signs after onset of orbital apex syndrome. After onset, the amount of steroid was increased from betamethasone 4 mg, and the converted amount of prednisolone was 26-60 mg. Ocular movement, visual acuity, and ptosis gradually improved thereafter. Vidarabine was also given for 12 days after the onset of orbital apex syndrome.. Abbreviations: OAS, orbital apex syndrome; DIV, intravenous injection by drip; BCVA, best-corrected visual acuity.
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Twelve weeks after onset, diplopia at the primary position disappeared, and the best-corrected visual acuity in the right eye improved to 1.0 (Figure 3).
Photographs of eye positions in all directions five months after initiation of therapy. (A) Most ocular movements are markedly improved, except for abduction. Subconjunctival hemorrhage is present in the left eye. (B) Photograph of face one month after initiation of therapy. The skin lesions are almost resolved but ptosis remains.
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Twenty weeks after onset, eye movements were almost completely recovered, except for abduction (Figure 4).