Background Orbital Apex Syndrome (OAS) is a disease of multiple brain nerves at the orbital apex leading to vision loss and neurological impairments. Diabetes Mellitus (DM), a metabolic disorder with cardiovascular, immunological and neurological effects, is involved in OAS pathogenesis. However, the association between DM and OAS is not well studied. DM and OAS are poorly understood and may not be diagnosed correctly, especially when outbreaks such as COVID-19 are being investigated. Methods A systematic review of 33 studies published between 2000 and 2025 was conducted to analyze DM-related OAS epidemiology, pathophysiology, clinical phenotypes, and treatment outcomes, focusing on the mechanistic links, pandemic trends, and glycemic control effect on therapeutic effectiveness. Results Chronic hyperglycemia induced orbital apex microvascular damage (endothelial dysfunction, thrombosis, vascular senescence), immunosuppression induced opportunistic infections (mostly mucormycosis), and diabetic neuropathy induced neuromuscular dysfunction. During COVID-19, diabetic patients had the highest OAS incidence (more than 70% of cases involved rhino-orbital mucormycosis). Optimal glycemic control is associated with a 32% higher antifungal treatment effectiveness and a 28% lower rate of surgical complications. Epidemiological data showed that DM was the main predisposing factor, with 71.4%–81.8% infectious OAS cases occurred in diabetic populations. Conclusion DM is underreported as a critical catalyst for OAS with complications directly increasing severity and progression. Routine DM screening (e.g., glycated hemoglobin monitoring) and integrated glycemic management are essential for OAS prevention and treatment. Long-term studies on inflammatory factors and personalized multidisciplinary care are needed to address mechanistic gaps and improve visual and neurological outcomes in high-risk diabetic patients.

Globe rupture presents a diagnostic challenge because of potentially vision-threatening outcomes. Although computed tomography (CT) is critical for assessment, a structured interpretation approach is often lacking. This study introduces the novel "FLAP CONE" mnemonic to assist radiologists in evaluating globe rupture. This was a retrospective study of 143 patients (151 eyes) with suspected globe rupture between January 2015 and December 2020. The male-to-female ratio was 3:1, with a median age of 22 years. Demographics and mechanisms of injury were recorded. CT scans were independently reviewed by two radiologists using the FLAP CONE mnemonic, encompassing Fractures/Foreign bodies, scleral Lacerations/Lens abnormalities, Anterior chamber changes, Posterior segment abnormalities, eye Contour distortion, Orbital apex hematoma, Neurovascular bundle abnormalities, and Extraocular muscles (EOM)/Emphysema. Findings were documented as binary variables. The diagnostic accuracy, sensitivity, specificity, and interobserver agreement (κ) were calculated. Sharp objects (39%) and falls (25%) were the leading causes of penetrating and blunt trauma, respectively. Use of the mnemonic achieved 91.9% diagnostic accuracy, with 88.3% sensitivity and 98.5% specificity. Orbital emphysema (43%) was the most frequent finding. Postseptal foreign body and the "flat tire" sign were associated with the highest diagnostic performance (sensitivity of 100% and 97.2%, respectively; specificity, 100%; and PPV, 100%). Kappa values ranged from 0.15 (orbital apex hematoma) to 1.0 (postseptal foreign body), with an overall κ = 0.85. Four clinically confirmed ruptures were missed because of subtle scleral defects and the presence of intraocular gas. The FLAP CONE mnemonic demonstrates excellent diagnostic accuracy and interobserver reliability, providing a systematic and efficient approach to the CT evaluation of globe rupture.

Resection is the foundation of spheno-orbital meningioma (SOM) treatment, but the confluence of critical neurovascular structures traversing the cranium and orbit and the unforgiving nature of orbital injury make resection of the tumor's orbital components challenging. Large series detailing surgical outcomes are rarely reported, and a surgical framework is needed. This study examined the feasibility of resection of SOMs with an involved orbit. The authors classified SOMs based on the relative orbital involvement to determine tumor resectability, with the goals of improving proptosis and functional visual outcome and avoiding new deficit. A retrospective chart review identified patients with surgically treated SOMs with a minimum 1-year follow-up at an academic center from 2002 to 2023. Imaging and clinical presentations and outcomes are reported, and a clinically relevant grading system is proposed based on imaging findings of orbital hyperostosis (grade 1), periorbital involvement (grade 2), intraorbital involvement without (grade 3a) or with (grade 3b) rectus muscle invasion, or involvement of the orbital apex or optic nerve (grade 4). Among 93 included patients (71% female), the mean age at surgery was 54.8 years. The most common presentations were proptosis (74.2%), visual decline (57.0%), and cranial neuropathies (30.1%). Gross-total resection of the orbital contents was achieved in 88.5%, 50.0%, 16.7%, and 24.1% of grade 1-4 tumors, respectively; it was less likely in grade 3 or 4 tumors (OR 0.06, 95% CI 0.019-0.190; p < 0.001), unless it was for oncological removal in a patient with no functional vision. Resection led to stable or improved vision in most patients across all grades (96.2%, 100%, 83.3%, and 93.1% in grade 1-4 tumors, respectively). Proptosis was less pronounced in grade 1 tumors, and the degree of proptosis was statistically more likely to improve with pronounced proptosis in higher-grade tumors (Δexophthalmos index 0.04, 0.14, 0.11, and 0.15 in grade 1-4 tumors, respectively). Overall surgical, visual, and ophthalmological morbidities were similar across all grades, and there were no deaths. This study introduces a grading system for SOMs and validates its utility through the assessment of surgical outcomes of a large patient cohort. This grading system allows for a better understanding of visual risks associated with surgery and facilitates comparisons across clinical studies. This may guide clinical management discussions and future research of this complex pathology.

Background: Orbital dermoid cysts are common benign lesions; however, deep-seated or recurrent lesions near the orbital apex pose major surgical challenges due to their proximity to critical neurovascular structures. Lateral orbitotomy remains the reference approach, but accurate osteotomies and stable reconstruction can be difficult to achieve using conventional techniques. This study reports our initial experience using a fully digital, hospital-based point-of-care (POC) workflow to enhance precision and safety in complex orbital dermoid cyst surgery. Methods: We present a case series of three patients with orbital dermoid cysts treated at a tertiary center (2024-2025) using a comprehensive digital workflow. Preoperative assessment included CT and/or MRI followed by virtual surgical planning (VSP) with orbit-tumor segmentation and 3D modeling. Cutting guides and patient-specific implants (PSIs) were manufactured in-house under a certified hospital-based POC protocol. Surgical strategies were tailored to each lesion and included piezoelectric osteotomy, intraoperative navigation, intraoperative CT, and structured-light scanning when indicated. Results: Complete en bloc resection was achieved in all cases without capsular rupture or optic nerve injury. Intraoperative CT confirmed complete lesion removal and accurate PSI positioning and fitting. Structured-light scanning enabled radiation-free postoperative monitoring when used. All patients preserved full ocular motility, visual acuity, and facial symmetry, with no complications or recurrences during follow-up. Conclusions: The integration of VSP, in-house POC manufacturing, and image-guided surgery within a lateral orbitotomy approach provides a reproducible and fully integrated workflow. This strategy appears to improve surgical precision and safety while supporting optimal long-term functional and aesthetic outcomes in challenging orbital dermoid cyst cases.

To discuss the anatomy of the optic strut (OS) and its implications for the diagnosis and treatment of vision loss caused by OS mucocele. We collected and analyzed 5 cases of OS mucocele with vision loss treated from 2013 to 2023, and reviewed literatures on nasal mucoceles and orbital apex anatomy. By comparing reported cases, we summarized the OS anatomical characteristics and their effects on patient symptoms. Concurrently, a comprehensive narrative literature review was conducted using PubMed, Embase, and Web of Science databases to identify studies on optic neuropathy caused by mucoceles in the OS and adjacent structures (anterior clinoid process, sphenoid sinus, ethmoid sinus). Relevant data were extracted for descriptive statistical analysis. All patients were followed up for 6 months postoperatively. One patient showed no significant vision improvement, while the other four had vision recovery: 0.5→1.2, 0.6→1.0, 0.7→1.0, and 1.0→1.2 (typical case). For the narrative literature review, 15 studies encompassing 48 cases were included, with 19 cases analyzed in detail. All 19 cases presented with vision loss (100%), accompanied by headache (68.4%) and afferent pupillary defect (APD, 47.4%) in partial cases. Lesions were confined to the anterior clinoid process in 4 cases and involved the sphenoid sinus in the rest, showing expansile features on CT and high T2 signal on MRI. Endoscopic endonasal surgery was adopted in 63.2% of cases; timely intervention achieved complete visual recovery in 52.6% of patients, whereas delayed treatment frequently led to optic atrophy. The OS is a bony structure separating the superior orbital fissure, optic canal, and internal carotid artery. OS mucocele-induced pressure elevation and inflammation can damage the optic nerve and cause vision loss. Prompt surgical resection and optic nerve decompression are critical for preserving visual function in patients with space-occupying lesions around the optic canal.

Objective: To analyze cases of intraorbital foreign bodies (IOFBs) removed via endoscopic transnasal or transorbital approaches from a single center and relevant literature reports, to summarize surgical techniques and diagnostic and therapeutic experiences, and to provide clinical references for endoscopic management of IOFBs. Methods: A total of 10 cases of IOFBs admitted to the Department of Otorhinolaryngology Head and Neck Surgery of the Affiliated Hospital of Qingdao University from September 2016 to September 2024 were collected. All patients were male, with the age of 47.00 (40.00, 66.50) years [M (Q1, Q3)]. Additionally, 20 related cases were retrieved via a comprehensive literature search. Surgical methods (endoscopic transnasal or transorbital approaches) for the removal of IOFBs were described, and clinical features, imaging findings, and therapeutic outcomes were analyzed. Descriptive statistical analysis was performed using Microsoft Excel 2019 software. Results: Most IOFBs removed via endoscopic transnasal or transorbital approaches were located deep in the orbit, and the majority of patients (6 from our single-center series and 15 from the literature review) presented with symptoms of orbital apex injury, including vision loss and limited ocular motility. The density of wooden IOFBs increased over time: initially, they appeared as low-density lesions on CT scans with Hounsfield units (HU) ranging from -330 to -120; after prolonged retention, they converted to hyperdense lesions with CT values of 90-200 HU. Patients with no light perception preoperatively showed poor visual recovery, while most cases of vision loss and limited ocular motility improved postoperatively. Infections and other related symptoms were effectively alleviated. Conclusion: Endoscopic transnasal or transorbital approaches are effective therapeutic methods for deep IOFBs.

A Case of Acute Invasive Fungal Infection of the Sphenoid Sinus Causing Orbital Apex Syndrome

A 72-year-old man developed herpes zoster ophthalmicus (HZO), involving the ophthalmic branch of the right trigeminal nerve. The rash completely resolved after a 7-day course of oral antiviral therapy. However, 21 days after the onset of the rash, he developed diplopia. A further 8 days later, he experienced visual impairment in the right eye. He was diagnosed with right abducens nerve palsy and retrobulbar optic neuropathy. Gadolinium-enhanced MRI revealed abnormalities around the optic nerve, extraocular muscles (the inferior, medial, and lateral rectus muscles), and the right orbital apex. Cerebrospinal fluid examination was normal, and VZV-DNA was not detected. Treatment with intravenous acyclovir and methylprednisolone led to improvement in visual function within 5 days. The diplopia also completely resolved within approximately 3 months. The pathophysiology was considered orbital apex syndrome caused by ischemia, inflammation, and edema secondary to vasculitis. This case highlights that HZO can cause diverse cranial nerve complications such as diplopia and visual impairment, even after the resolution of skin lesions.

Due to the variable course of thyroid eye disease (TED), treatment should be tailored to disease severity, individual risk factors, and clinical course. This study is based on a retrospective analysis at the orbital centre of the University Eye Clinic Essen and evaluates the efficacy of the IL-6 receptor blocker tocilizumab as a second-line therapy in patients with therapy-refractory TED. After approval of cost coverage, 20 patients were treated with tocilizumab over a mean period of 4.8 ± 2.7 months. The following parameters were assessed: sex, age, underlying thyroid disease, disease activity and severity, prior therapies, visual acuity, intraocular pressure, eyelid position, exophthalmos, monocular excursions, strabismus/diplopia, levels of TSH receptor antibodies (TRAb), and adverse events. The female-to-male ratio was 3 : 1. Mean patient age was 58.2 ± 8.5 years. The majority (90%, n = 18) had Graves' disease; one patient had primary hypothyroidism and one was euthyroid. All patients had previously failed various treatment regimens (median cumulative steroid dose 4.6 g [1.5 - 7.5 g], 55% mycophenolate, 65% orbital apex radiation, 20% balanced orbital decompression). Among 17 patients with detectable TRAb at baseline, mean antibody levels decreased by 48.4%. A reduction of at least 30% was achieved in 70.6% of these patients (n = 17). A decrease in the Clinical Activity Score (CAS) by ≥ 2 points was observed in 70% of cases. The mean inflammation score (maximum 20 points per patient) decreased from 8.8 ± 3.9 to 3.4 ± 2.4. The effect on exophthalmos was moderate: mean reduction was 0.9 ± 1.8 mm (range - 6 mm to + 3 mm). A decrease of ≥ 2 mm was documented in 25% of patients, whereas an increase was noted in 12.5% (0.5 to 3 mm). Improvement in ocular motility was documented in 22.5% of patients, while 10% showed deterioration. This cohort exclusively included therapy-refractory patients, some with protracted disease. The significant reduction in inflammation and particularly in TRAb levels, as a biomarker of disease activity, demonstrate the efficacy of tocilizumab in this highly selected population. Tocilizumab may therefore be an important treatment option for patients with high antibody levels and predominantly inflammatory disease manifestations. Further studies are warranted to evaluate whether it reduces the risk of relapse after successful treatment with an IGF-1 receptor blocker.

Idiopathic orbital inflammatory disease (IOID) is a non-specific orbital inflammatory condition that is uncommon in children. Due to limited data and the unique characteristics of the developing immune system in children, this study examined the clinical features, imaging subtypes, treatment outcomes, and recurrence patterns. Pediatric patients (≤ 18 years) diagnosed with IOID at Beijing Tongren Hospital, Capital University between January 2020 and January 2025 were included in this retrospective review. Clinical data, imaging characteristics, treatment regimens, and recurrence patterns were collected. Cases were further classified into six anatomical subtypes based on orbital imaging. A total of 10 patients (12 eyes) were included, with a mean age of 9.9 ± 3.2 years. Imaging subtypes included diffuse (5, 50%), posterior scleritis (3, 30%), dacryoadenitis (1, 10%), and orbital apex involvement (1, 10%). Clinical symptoms were conjunctival injection (9, 90%), optic disc edema (8, 80%), decreased visual acuity (8, 80%), eyelid swelling (7, 70%), periorbital pain (6, 60%), ocular pain (4, 40%), and ptosis (4, 40%). Orbital MRI revealed posterior scleral and/or Tenon's capsule thickening with enhancement (8, 80%), optic nerve or sheath enhancement (5, 50%), lacrimal gland enlargement (4, 40%), and cavernous sinus thickening or dural enhancement (2, 20%). All patients received systemic corticosteroids, with a mean follow-up duration of 17.9 ± 12.5 months. Nine patients experienced recurrence, with seven of them related to steroid dependence in diffuse-type cases. Final visual acuity was ≥ 0.3logMAR in all relapsed cases. Pediatric IOID frequently presents with diffuse or deep orbital involvement on imaging. While corticosteroid therapy is generally effective, these subtypes may be more prone to steroid-dependent relapse during tapering. The association between steroid tapering and relapse remains to be fully substantiated, and further studies are needed to explore this potential relationship. Imaging-based classification may help predict recurrence risk and guide individualized long-term management strategies for pediatric IOID.

Objective: To describe a rare cause of acute isolated sphenoid sinusitis in an adult, immunocompetent, female, complicated by meningitis due to a clival abscess and subsequent development of orbital apex syndrome, originating from an infected pneumatized anterior clinoid process (ACP) Methods: We present a case report of a 61-year-old, healthy, female, who presented with a one-week history of fever, upper respiratory tract infection symptoms, and severe headache. Initial computed tomography (CT) of the head revealed isolated sphenoid sinusitis with posterior wall dehiscence communicating with the prepontine subarachnoid space. She underwent an endoscopic transseptal repair of the clival defect with a nasoseptal flap, followed by a three-week intravenous antibiotic regimen. Apart from consistent headaches, her postoperative course was unremarkable. Four months later, she presented with orbital apex syndrome. Magnetic resonance imaging (MRI) revealed mucosal disease in a pneumatized ACP. She underwent a second surgical intervention including a left-sided sphenoidectomy, orbital and optic canal decompression. Results: Initial surgical management successfully addressed the intracranial infection. However, persistent headaches and delayed onset of orbital apex syndrome occurred despite unremarkable interim imaging and endoscopy. A gadolinium-enhanced MRI ultimately identified inflammation within the pneumatized ACP, when the patient presented with orbital apex syndrome. Intraoperative cultures during the second surgery grew Pseudomonas, for which she underwent prolonged intravenous antibiotic therapy. There has been marked improvement in her symptoms, with a remaining mild sixth cranial nerve palsy and postnasal drip at her most recent follow-up. Conclusion: Isolated sphenoid sinusitis, especially involving a pneumatized ACP, can present insidiously and lead to serious intracranial and orbital complications despite early intervention. High clinical suspicion and early use of MRI are essential in patients with persistent symptoms and subtle imaging findings. Multidisciplinary management and long-term follow-up are crucial for optimal outcomes.

BackgroundDysthyroid optic neuropathy (DON) is a vision-threatening complication of thyroid-associated ophthalmopathy (TAO). The underlying pathophysiology is believed to involve compression of the optic nerve at the orbital apex, primarily due to edema and volumetric expansion of orbital soft tissues. Early detection of DON is crucial to prevent irreversible visual loss. However, reliable imaging biomarkers for early diagnosis remain limited. This study aimed to investigate whether orbital soft tissue volume and water fraction (WF), derived from three-dimensional cube fast spin-echo Flex (3D Cube FSE-Flex) magnetic resonance imaging (MRI), can serve as predictive markers for DON in TAO patients.MethodsIn this retrospective study, 3D Cube FSE-Flex MRI images and clinical data were analyzed from 60 patients with TAO (27 with DON, 33 without). A total of 116 orbits (53 with DON, 63 without) were included. Quantitative measurements of extraocular muscle volume (EOMV), water fraction of extraocular muscles (EOM-WF), and orbital fat (OF-WF) were obtained using semi-automated segmentation. Group comparisons were performed using appropriate statistical tests. Logistic regression was used to identify risk factors for DON, and receiver operating characteristic (ROC) curve analysis was employed to evaluate diagnostic performance. Correlation analysis was conducted to assess relationships between imaging parameters and clinical activity scores (CAS).ResultsDON orbits showed significantly higher EOMV, EOM-WF, and OF-WF compared to non-DON orbits (all P<0.001). Logistic regression revealed that increased EOMV [odds ratio (OR) =1.555; 95% confidence interval (CI): 1.250–1.934] and higher OF-WF (OR =1.190; 95% CI: 1.064–1.332) were independent risk factors for DON. A combined model incorporating EOMV and OF-WF demonstrated good diagnostic performance [area under the curve (AUC) =0.843]. Additionally, both EOMV (P=0.015, r=0.333) and OF-WF (P=0.025, r=0.308) were positively correlated with CAS.ConclusionsQuantitative MRI analysis using 3D Cube FSE-Flex reveals that enlargement and edema of orbital soft tissues—specifically EOMV and OF-WF—are significant risk factors for DON. The combination of these parameters provides a robust imaging biomarker for early identification of DON in TAO patients, with potential clinical utility in risk stratification and treatment planning.

Abstract Background Imaging the trigeminal nerve (TN) presents significant challenges due to its extensive pathway from the brainstem nuclei to its peripheral branches, as well as its complex anastomotic network either through its numerous branches or connections with the facial nerve, which often complicates a topographic approach. Various pathologic conditions may affect each segment of the trigeminal nerve, MRI is the preferred imaging technique for evaluating the majority of conditions that involve various segments of the trigeminal nerve. The majority of the literature surrounding the trigeminal nerve although encompasses a variety of perspectives, but it is focusing on trigeminal nerve involvement in perineural spread from locoregional malignancies and neurovascular compression conflicts. This research manuscript is meant to concentrate on the less familiar trigeminal nerve lesions, escalating perineural sheath of segments distal to the porus trigeminus; those encompassing Meckel’s cave and the cavernous sinus, extending to its peripheral branches, while excluding the preganglionic and brainstem segments. Patients and methods The purpose of our current research is that we can report herein our experience in imaging of different trigeminal nerve related masses, starting from distal to porus trigeminus, so we can separate head and neck/skull base from scope of neuro-radiology. Also, we termed them “non-vascular” to exclude vascular loops, cavernous sinus thrombosis and cortico-cavernous fistulas. This retrospective case study aimed to collect patients’ data from the Archives of radiology department, from January 2022 to January 2024 including MRI imaging data and final pathology results, which were extracted from patients primarily referred for imaging from the “oncology,” “neuro-surgery” and “oto-rhino-laryngology” ward. The “Ethics Committee” of our medical institution approved our proposed protocol. Results Our study had enrolled 48 cases: 24 men and 24 women, with ages ranging between 12 and 79 years, showing a mean of 43 years. The predominant pathology was schwannomas (n = 15), followed by inflammatory pseudotumor/ IGg4 disease ( n = 11), followed by meningioma ( n = 9), followed by metastases ( n = 7). The Cavernous sinus (CS) was the prevalent epicenter location of pathologies ( n = 34; 70% of cases), followed by Meckel’s cave (MC), and Masticator space (MS) and PPF-pterygo-palatine fossa ( n = 3 for each), followed by orbit and orbital apex (sites of V1). Conclusions Perineural spread along the TN is not limited to PNTS from locoregional head and neck malignancies and has more wide differential diagnosis, and differential list includes quite less common lesions. These unfamiliar lesions of the TN involve the nerve in a similar perineural pattern and yet imaging features are overlapping with common PNTS from local malignancies, making optimal diagnosis a difficult task without pathology confirmation. However, radiologists should be aware of such uncommon lesions which should be included in differential diagnosis of PNTS.

Costello Syndrome (CS) results from a germline mutation in the HRAS gene. Rhabdomyosarcoma in CS patients has arisen from various sites but not the orbit. We present the first case report of orbital rhabdomyosarcoma in a patient with CS. An 18-month-old male known for CS presented with progressively worsening proptosis and periorbital edema. On presentation, he had proptosis with inferolateral globe displacement, chemosis and injection. An urgent computed tomography scan revealed a left orbital mass extending from the posterior aspect of the globe to the orbital apex, and pathological examination confirmed embryonal rhabdomyosarcoma. Treatment with chemotherapy consisted of vincristine, dactinomycin, and cyclophosphamide, and received 8 cycles of photon beam radiation. Radiological surveillance up to 12 months showed no signs of recurrence or metastatic lesions. Patients with CS are at a high risk of developing rhabdomyosarcoma and clinicians should be vigilant in the context of any clinical orbital signs of disease.

Chronic Rhino Orbital Mucormycosis as a Rare Etiology of Orbital Apex Syndrome in a Patient with Diabetic Ketoacidosis: A Case Report

Unilateral orbital pain and oculomotor paresis are hallmark features of Tolosa-Hunt Syndrome - a rare cause of painful ophthalmoplegia that demonstrates rapid symptom relief following corticosteroid therapy. Approximately 40% of affected individuals experience recurrence, either ipsilaterally or contralaterally. We present a case of a 60-year-old woman with complaints of left-sided retro-orbital pain accompanied by eyelid drooping and diplopia that had started two weeks prior. Her past and family history were negative. Magnetic resonance imaging of the brain revealed abnormal enlargement of the left cavernous sinus, appearing hypointense on T1WI and hyperintense on T2WI (A, B), with an incidental finding of an empty sella (C). On neurological examination, the patient had hypoesthesia in the trigeminal nerve´s V1 distribution and left ipsilateral third and fourth cranial nerve palsy (D). The enlarged left cavernous sinus showed post-contrast enhancement (E, F) extending through the superior orbital fissure into the orbital apex. The left optic nerve appeared mildly tortuous and enlarged, with intraocular kinking and hyperintensity on T2-weighted images, along with subtle contrast enhancement (G). A comprehensive evaluation ruled out alternative causes involving the cavernous sinus. The patient's symptoms resolved within 72 hours of initiating corticosteroid therapy, supporting a diagnosis of Tolosa-Hunt Syndrome secondary to idiopathic granulomatous inflammation of the cavernous sinus. She was advised to have regular follow-ups due to the risk of recurrence.

Transorbital endoscopic approaches: Applications in orbital surgery.

Giant-cell tumors of bone (GCTBs) are benign, expansile lesions usually found in the long bones of young adults. The authors report a pediatric skull base GCTB causing cranial nerve deficits and vision loss. The patient presented with blurry vision, left eye misalignment, headaches, nausea, and vomiting. Imaging revealed a large heterogenous mass invading the anterior cranial fossa floor. Initial histopathology suggested an aneurysmal bone cyst (ABC), and the mass was surgically resected. Four months later, recurrence led to genetic testing, which identified a p.G35W H3F3A mutation, confirming GCTB with secondary ABC of the pituitary fossa causing right compressive optic neuropathy and left orbital apex syndrome. Management included repeat resection and denosumab therapy, achieving radiographic stability with preservation of vision in the right eye, although the optic nerve of the left eye remained atrophic. Given the diagnostic overlap between GCTB and ABC, the authors emphasize the importance of genetic testing for accurate and early diagnosis to enable timely treatment and reduce the risk of recurrence.

While orbital apex syndrome is considered a rare condition, it has significant neuro-ophthalmic implications for diagnosis and management. It is characterized by the involvement of the following cranial nerves: the optic nerve, the oculomotor nerve, the trochlear nerve, the abducens nerve, and the first division of the trigeminal nerve, manifesting as clinical symptoms upon their impairment. Although various factors can be causal, trauma can also lead to the development of orbital apex syndrome. Regardless of the cause, treatment often involves inducing decompression of the orbital space using steroids. We present a case demonstrating symptomatic improvement through surgical reduction of a fractured bone in a patient who was diagnosed with orbital apex syndrome due to trauma, in addition to steroid therapy. This case underscores surgical intervention as a viable approach to enhance decompression in cases where orbital space narrowing is observed following trauma-induced fracture in orbital apex syndrome patients.

Tolosa–Hunt syndrome (THS) is a rare, idiopathic granulomatous inflammation of the cavernous sinus, superior orbital fissure, or orbital apex, characterized clinically by painful ophthalmoplegia. We report the case of a 53-year-old woman with a five-month history of right periorbital headaches. MRI revealed enlargement of the right cavernous sinus with convex dural margins, iso- to slightly hyperintense T2 signal, and marked homogeneous enhancement after gadolinium administration. There was possible focal narrowing of the cavernous segment of the ipsilateral internal carotid artery, without bone erosion or mass effect. Follow-up MRI after four months of corticosteroid therapy demonstrated significant regression. This case highlights the role of MRI in diagnosing Tolosa–Hunt syndrome and monitoring therapeutic response.