Limitation Of Extraocular Movements Research Articles

Orbital complications of paranasal sinusitis in Taiwan, 1988 through 2015: Acute ophthalmological manifestations, diagnosis, and management.

PurposeParanasal sinusitis is widespread and can lead to orbital complications, blindness, and death. However, the correlation between ophthalmological findings and disease staging remains unclear. This study aimed to investigate the staging, acute ophthalmological manifestations, diagnosis, management, and outcomes of orbital complications of paranasal sinusitis during a 27-year period.MethodsWe retrospectively reviewed the medical records of all patients with orbital complications of paranasal sinusitis hospitalized at the National Cheng Kung University Hospital, a medical center in Taiwan during 1988–2015. Sex, age, symptoms, history, ophthalmological findings, laboratory and imaging findings, treatments, and outcomes were analyzed by staging.ResultsEighty-three patients aged 9 days to 80 years had stage I (preseptal cellulitis, n = 39 patients), II (postseptal orbital cellulitis, n = 8), III (subperiosteal abscess, n = 16), IV (orbital abscess, n = 8), or V (intracranial involvement, n = 12) complications. Peak incidences occurred in patients aged 0–19 and 60–69 years. Chronic sinusitis and diabetes mellitus were common preexisting diseases. Extraocular movement limitation and proptosis predicted postseptal (stage II or more) involvement. The likelihood of elevated intraocular pressure increased with stage. Reduced visual acuity and presence of relative afferent pupillary defect indicated consideration of magnetic resonance imaging to investigate possible intracranial extension. Ipsilateral maxillary (81.7%) and ethmoidal (75.6%) sinuses were the most common sources of infection, and the most frequently implicated pathogens were coagulase-negative Staphylococcus spp. (25.3%) and Staphylococcus aureus (20.5%). All patients received intravenous antimicrobial therapy (multi-drug therapy in 88.0%), and 55.4% underwent surgery, most commonly endoscopic sinus surgery. One (1.2%) diabetic man with stage V complications died of fungal sinusitis with intracranial invasion. Five (6.0%) patients, all stage V, lost vision despite intensive treatment. The average length of hospital stay was 13.8 days (range 2–72 days), and significantly longer stays were associated with stages II–V as compared to stage I.ConclusionsOrbital infection originating from paranasal sinusitis can cause vision loss and death due to intracranial extension. Acute ophthalmological findings predict staging and prognosis. Cooperative consultation between ophthalmologists, otorhinolaryngologists, and neurologists is essential. Urgent diagnostic studies and aggressive antimicrobial therapy are indicated, and surgery should be considered.

Reconstruction of Orbital Floor With Auricular Concha.

Orbital floor fractures of varying sizes commonly occur after orbital injuries and remain a serious challenge. Serious complications of such fractures include enopthalmos, restriction of extraocular movement, and diplopia. There is a dearth of literature that can be applied widely, easily, and successfully in all such situations, and therefore there is no consensus on the treatment protocol of this pathology yet. Autogenous grafts and alloplastic and allogenic materials with a wide variety of advantages and disadvantages have been discussed. The value of preoperative and postoperative ophthalmological examination should be standard of care in all orbital fracture patients. An ideal reconstructed orbital floor fracture should accelerate the restoration of orbital function with acceptable cosmetic results. Management parameters of orbital fractures such as timing of surgery, incision type, and implant materials, though widely discussed, remain controversial. In this study, 55 patients with orbital floor fractures surgically reconstructed with conchal cartilage grafts between 2008 and 2014 were retrospectively evaluated. Complications and long-time follow-up visit results have been reported with clinical and radiographic findings. The aim of this study was to present the authors' clinical experiences of reconstruction of blow-out fractures with auricular conchal graft and to evaluate the other materials available for use.

Extra-ocular movement restriction and diplopia following orbital fracture repair

PurposeTo report a series of patients with extra-ocular movement restriction and diplopia after orbital fracture repair, and determine the effect of timing of repair and the type of implant used. MethodsA chart review was conducted identifying all patients >18years of age at our institution between June 2005 and June 2008 who underwent orbital fracture repair, and presented with clinically significant diplopia and extra-ocular movement restriction persisting longer than one month after repair. Data collected included timing of repair, implant used within the orbit, and need for revision. ResultsTen patients were identified with a mean time to primary orbital fracture repair at 9days (range 1–48). Seven patients underwent revision of their orbital fracture repair with removal of the previously placed implant and replacement with non-porous 0.4mm Supramid Foil, whereas one patient underwent lateral and inferior rectus recessions without revision of primary fracture repair. Titanium mesh was the intra-orbital implant found in all patients requiring revision of orbital fracture repair. All revisions resulted in resolution of clinically significant diplopia. ConclusionsClinically significant diplopia and extra-ocular movement restriction is not an uncommon complication after orbital fracture repair. In our series, there was a strong association between these complications and the use of porous titanium mesh implants. Revision of fractures significantly improved diplopia in all but one patient. This suggests that meticulous fracture repair and the use of non-porous implants primarily or secondarily may preclude the need for strabismus surgery after orbital trauma.

The progress of imaging diagnostic of orbital blowout fracture

Orbital blowout fracture occurs only on the medial wall and (or) the floor(inferior wall) of orbit, and orbital rim integrity.It is different from the compound orbital fractures. Contents of orbital with hemiation or entrapment in ethmoid sinus and/or maxillary sinus, lead to serious consequences such as extraocular movement limitation and enophthalmos. Its diagnosis mainly based on imaging. In recent years, with the development of imaging technology, especially the new technology applications of multisliecs spiral computed tomography (MSCT) multiplanar reconstructions (MPR) of two-dimensional (2D) images, volumetric rendering (VR) three-dimensional (3D) images, high-resolution magnetic resonance imaging (MRI) and dynamic MRI, in the diagnosis and clinical evaluation of orbital blowout fracture made some progress. Key words: Orbital fracture, blowout; Tomography, spiral, computed; Magnetic resonance imaging; Ultrasonography

Abstract 37. Pediatric Orbital Floor Fractures: Clinical and Radiological Predictors of Tissue Entrapment and the Effect of Operative Timing on Ocular Outcomes

Purpose: To determine the clinical and radiological predictors of tissue entrapment in pediatric orbital floor fractures and to explore the effect of operative timing on ocular outcomes. Methods: We retrospectively reviewed the medical records of pediatric patients (aged <18 years) who acutely presented with orbital floor fractures from October 2007 to October 2015. Results: 152 patients with 159 orbital floor fractures were included. 122 (80.3%) patients were male, and the mean age was 12.2 years. Twelve patients (7.9%) sustained orbital floor fractures with tissue entrapment. At presentation extraocular movement (EOM) restriction, diplopia, nausea, and vomiting were all associated with tissue entrapment (P<0.001). Amongst patients with trapdoor fractures, the presence of nausea and/or vomiting was predictive of tissue entrapment: positive predictive value 80%, negative predictive value 100%. For patients with tissue entrapment, poorer ocular outcomes (persistent EOM restriction and diplopia) were significantly associated with the length of operation (P=0.007), but not with the time interval to operation (P=0.146). Conclusion: Nausea and vomiting are valuable predictors of tissues entrapment, particularly when EOM restriction and diplopia are equivocal. In our study, radiological findings were predictive of entrapment, but a lack of consistent language in this area limits the external validity of these results. Our study draws attention to the relationship between operation length and poorer ocular outcomes, suggesting that case severity/complexity and surgeon technique/experience may influence ocular outcomes.

Kimura's Disease: Uncommon Cause of Proptosis

Purpose: To describe a case of inferior orbital mass with generalized lymphadenopathy and histopathological examination proven Kimura’s disease. Methodology: Case report Findings: A 17 year-old Malay man with no previous illness. Presented with two months history of progressive proptosis of the right eye (RE). Upon presentation vision was 6/7.5 RE and left eye (LE) 6/6. Ocular examination revealed RE proptosis with restricted extraocular muscle movement and optic disc swelling. Systemic examination noted multiple lymphadenopathy over cubital fossa and inguinal region. Blood investigation showed peripheral eosinophilia. CT brain and orbit revealed RE inferior orbital mass compressing the optic nerve. Subsequently RE orbital mass incisional biopsy and inguinal node excisional biopsy was done. The later showed typical features of Kimura’s disease with diffuse eosinophils infiltration within the germinal centres of the lymphoid nodule. He was started on tapering dose of oral corticosteroids and responded well evidenced by reducing RE proptosis. Conclusion: This case demonstrates that proptosis with lymphadenopathy does not always imply lymphoma but may have a benign pathogenesis such as Orbital Kimura’s disease. Therefore it should be considered in the differential diagnosis of orbital lesions occurring in adults. Accurate diagnosis in biopsies is also crucial to avoid unnecessary radical surgery.

Frontal Bone Fracture Extending into the Roof and Medial Wall of Orbital Fracture Causing Diplopia

Fractures of the anterior cranial fossa can extend into the orbit and, if not detected early, can lead to either acute (e.g., diplopia, retrobulbar hematoma, and enophthalmos) or chronic complications (e.g., diplopia, restricted extraocular movement, ectropion, and enophthalmos). We report a case of a 15-year-old male child who sustained frontal bone fracture extending into the orbit. He had swelling of the right eye, and once the swelling subsided, he complained of diplopia. Computed tomography scan of the brain showed comminuted depressed frontal bone fracture extending more on the right side—the fracture was extending into the right orbital roof and associated fracture of the right medial orbital wall. The child underwent elevation of depressed bone fragments including decompression of the medial rectus muscle. Frontal bone fragments was replaced and secured with miniplates and screws. His diplopia completely recovered and he is doing well at follow-up.

Postoperative Improvement of Diplopia and Extraocular Muscle Movement in Patients With Reconstructive Surgeries for Orbital Floor Fractures.

With orbital floor fracture incidence rates increasing year by year, many patients require surgical treatment to improve diplopia, limitation of extraocular muscle movement (EOM), enophthalmos, and midface appearance. With the use of high-density polyethylene, titanium screws, titanium plate, and titanium mesh to repair an orbital floor fracture, enophthalmos and midfacial deformity correction procedures have made great progress. However, attenuating diplopia and the limitation of EOM are still difficult problems to prevent. The clinical data of 92 patients with reconstructive surgeries after orbital floor fracture were prospectively studied. The position, range of fracture, and incarceration of extraocular muscles were determined by computed tomography scanning. A Hess screen and a synoptophore examination were used to determine the EOM and diplopia. The Hess area ratio (HAR%) and the grade of diplopia were measured before and 1, 3, and 6 months after surgery. Diplopia was evaluated, and the severity was recorded accordingly. Diplopia rates in patients with simple orbital floor fracture showed a significant difference preoperatively and postoperatively at 1 and 3 months (P < 0.05) compared with diplopia rates at 6 months and 12 months after operation, which had no significant difference (P > 0.05). There was a statistically significant difference (P < 0. 05) among patients with an orbital floor fracture who had an operation within 3 weeks or more than 3 months after injury. Compared with preoperative and postoperative findings at 1 and 3 months, the limitation of EOM in patients with orbital floor fractures had a significant difference (P < 0.05); however, compared with 3 and 6 months after operation, there was no significant difference (P > 0.05). There was a statistically significant difference (P < 0.05) in patients with orbital floor fractures having had an operation within 3 weeks and more than 3 months after injury. The difference of improvement for diplopia after operation among HAR% < 65%, 65% ≤ HAR% ≤ 85%, and HAR% >85% groups were statistically significant (P <0.05). Postsurgically, the HAR% of the patients was improved, and the difference of HAR% between patients before and after the operation was statistically significant (P < 0.05). Surgical management can effectively improve diplopia and EOM disorder of patients with orbital floor fractures. Improvement statistics were calculated by a Hess screen and a synoptophore. Hess area ratio is a useful method to convert the Hess screen into a numerical value and can therefore be used to compare patients in clinical treatment of orbital wall fracture.

Orbital Cellulitis with Exudative Retinal Detachment

Exudative retinal detachment occurs extremely rarely with orbital cellulitis. TB can affect majority of the structures of the eye with marked variability of the lesions. We herein report a 40 year old male who presented with acute left eye protrusion with sudden diminution of vision. On examination there was proptosis of the left eye with restricted extraocular movements. Exudative retinal detachment with subretinal abscess was present in the same eye. Magnetic Resonance Imaging (MRI) of brain showed right sided frontal lobe lesion suggestive of tuberculoma with positive Quantiferon - TB Gold test.

Principles for Management of Orbital Fractures in the Pediatric Population: A Cohort Study of 150 Patients.

Pediatric orbital fractures represent a challenging and sometimes controversial clinical problem. Patients may present with clear indications for surgery, but most require balancing benefits against intraoperative and late complications. The authors assessed these fractures at a state-designated ophthalmology referral center to develop criteria for surgery. Institutional review board approval was obtained to retrospectively analyze pediatric trauma registry patients with orbital fracture diagnoses at the Wilmer Eye Institute over 10 years. Patients were excluded if they did not undergo a full ophthalmologic examination, never followed up after their injury, or had significant facial fractures outside of the orbit. One hundred fifty patients met selection criteria; 116 patients (77 percent) completed all follow-up (average, 309 days). Two patients had 20/40 vision or worse at the end of follow-up. One hundred ten patients (71 percent) underwent surgery; 96 underwent acute repair (<3 weeks) and 11 underwent delayed repair (median, 49 days). Three patients required reoperation, two for plate infection and one for hyperglobus, with an overall complication rate of 4.7 percent. The authors analyzed the largest series of operative pediatric orbital fractures to propose criteria for surgical intervention. There are four potential indications: (1) rectus muscle entrapment; (2) early enophthalmos; (3) central-gaze diplopia or extraocular movement restriction after the resolution of swelling; and (4) loss of orbital support likely to produce secondary changes in globe position and/or binocular stereo vision. In our series, application of these principles offered excellent long-term aesthetic and ophthalmic outcomes with an acceptably low complication profile. Therapeutic, III.

Delayed Superior Orbital Fissure Syndrome After Reconstruction of Blowout Fracture

The superior orbital fissure syndrome (SOFS) has been known to be a condition caused by impairment of the nerves that cross the superior orbital fissure. Traumatic SOFS is an uncommon complication which occurs usually within 48 hours after a facial injury. A 25-year-old male sustained facial trauma following an altercation. Clinical findings on presentation included swelling, ecchymosis, hyphema, subretinal hemorrhage, and mild extraocular movement limitation upon lateral gaze on his right eyelids. Facial computed tomography scan confirmed fractures of the medial walls of the right orbit and herniation of orbital soft tissue without the incarceration of medial rectus muscle. Ten days after the trauma, the operation was performed. On postoperative day 16, the patient showed ptosis of the right upper eyelid with a fixed pupil, and there was a hypoesthesia over the distribution of the right supraorbital and supratrochlear nerves. The authors diagnosed as a delayed SOFS and prescribed 4 mg of methylprednisolone q.i.d. for 30 days. After steroid therapy, extraocular movement limitations improved progressively. After 8 months, movement was completely restored. The authors experienced delayed SOFS on posttrauma day 27, and it was treated by steroid therapy. Surgical intervention is required when there is an evident etiology such as underlying hematoma or plate migration. If the reason is not clear like our case, steroid therapy can be considered as one of the options. Particularly, the authors should give special attention to the patient who has congenitally narrow superior orbital fissure, like Fujiwara et al suggested.

Long-term outcomes of strabismus surgery in Möbius syndrome

Möbius syndrome is a rare disorder characterized by presumed congenital sixth and seventh nerve palsies. Approximately half of affected patients have esotropia with limitation of extraocular movements. This study reviewed the long-term outcome of strabismus surgery for such patients.

Analysis of symptoms according to areas of orbital floor in orbital inferior wall fractures.

A considerable number of patients experiencing facial trauma are diagnosed with blowout fracture. Preoperative computed tomographic scan is often different from the actual surgical area. This study is restricted to orbital floor fracture. This study is expected to help speculating fracture site and making surgical plans according to symptoms of periorbital trauma. From March 2005 to September 2013, a total of 150 cases of orbital floor fracture surgeries have been analyzed. This study analyzed the preoperative symptoms at the certain fractured area of orbital floor, at the aspects of sagittal view of computed tomography, which is sectioned into anterior one-third, middle one-third, posterior one-third, and mixed types. Symptoms for analysis are diplopia, extraocular movement limitation, enophthalmos and other combined facial bone fractures, and the like. Fracture areas of orbital floor are 21 cases (14%) of anterior one-third, 47 cases (31%) of middle one-third, 7 cases (5%) of posterior one-third, and 75 cases (50%) of the mixed. Frequency of diplopia was 0 case, 24 cases (42.1%), 4 cases (7.0%), and 29 cases (50.9%), respectively. In the case of extraocular movement limitation, 0 case, 15 cases (39.5%), 2 cases (5.3%), and 21 cases (55.2%) were found, respectively. In the case of enophthalmos, 0 case, 5 cases (16.7%), 7 cases (23.3%), and 18 cases (60.0%) were found, respectively. The most commonly associated other facial bone fractures were nasal bone fractures. In the case of blowout fracture, diplopia, extraocular movement limitation, enophthalmos, and other symptoms are checked through physical examination. This study would help speculating fracture site and making surgical plans according to symptoms of periorbital trauma.

Surgical outcomes of orbital trapdoor fracture in children and adolescents

PurposeOrbital trapdoor fractures are uncommon but more frequent in children and adolescents. Orbital trapdoor fractures have been discussed in many previous reports, early treatment has been advocated but there is controversy over treatment policy and surgical outcomes. Our retrospective study analyzed the surgical outcomes of orbital trapdoor fracture in children and adolescents to investigate the appropriate timing of treatment and the relationship between severity of extraocular muscle movement (EOM) limitation before the operation and the period of recovery after operation. MethodsA total of 44 children and adolescents with orbital wall fractures were operated on from 2009 to 2013. This study included 25 patients who underwent surgery for orbital trapdoor fractures; age range 9–18 years (mean age 14.0). We investigated the interval from trauma to surgery, the period of full EOM recovery after operation and the correlation between these factors, retrospectively. ResultsThe mean follow-up duration was 90.2 days. At follow-up, nine out of ten patients who underwent surgery within 24 h (Group 1) had full EOM recovery, with a mean recovery time of 25.1 days; five out of six patients who underwent surgery within 24–72 h (Group 2) had full EOM recovery with a mean recovery time of 60.2 days; and seven out of nine patients who underwent surgery after 72 h (Group 3) had full EOM recovery with a mean recovery time of 67.6 days. There was no statistical difference in the operation success rates between the groups. Also, the four patients that not completely recovered EOM had a mild EOM limitation below grade −1. ConclusionIn our study, we found that patients with orbital trapdoor fractures can recover full EOM regardless of the interval from trauma to surgery. Therefore, we suggest that appropriate surgical technique is important in the treatment of patients with orbital trapdoor fractures, in addition to the urgent surgery recommended for these fractures in a pediatric population. Furthermore, we expect a good prognosis following the treatment of orbital trapdoor fractures if appropriate surgical techniques are used, even if a relatively long time has passed after the trauma.

Retrospective analysis of 301 patients with orbital floor fracture

The purpose of this study was to retrospectively analyse patients with orbital floor fracture who were treated at the Department of Odontostomatology and Maxillofacial Surgery, Policlinico Umberto I, Sapienza University of Rome, Italy, between 2008 and 2013. Patients were evaluated by age, sex, aetiology, clinical findings, fracture pattern, ocular injury, treatment, complications, and sequelae. We evaluated surgical outcomes and complications with the use of different surgical approaches and various materials used to reconstruct the orbital floor. In total, there were 301 orbital fractures. Two hundred and seventeen patients were men (72.1%) and 84 were women (27.9%). The average age of the patients was 37.2 years (range, 9–90 years). The leading cause of these fractures was violent assault (27.3%). Pure blow-out fractures (50.2%) were the most represented pattern, followed by zygomatic complex (46.5%). The most common symptom was hypoesthesia extending through the territory of the second trigeminal branch (TBH; 32.9%). Diplopia was present in 20.2% of patients followed by enophthalmos (2.3%) and extraocular movement limitation (1.7%). Ocular symptoms significantly improved following surgical repair. The most common postoperative complications included TBH in 34.2%, scarring 26%, and diplopia in 16.4% of the patients.

Subconjunctival cysticerscosis with involvement of superior muscle complex - a case report

Cysticercosis is a parasitic infestation caused by cysticercus cellulose. Ocular and adnexal cysticercosis represents 13% to 46% of systemic disease. There are different modes of presentation of ocular cysticercosis. Case: Here we report a case with the left upper eyelid ptosis. On ocular examination, there was presence of a cystic yellowish mass of size of the eye ball in the upper palpebral sub-conjunctiva along with dystropia and limitation of extraocular movements in dextroelevation. Complete surgical excision of the cyst was achieved through splitting of the left upper eyelid. There was presence of sub-conjunctival cyst along with involvement of levator palpebral superioris (LPS) and superior rectus (SR) muscle. Histopathological examination of the cyst showed features suggestive of cysticercosis. The patient was symptomatically better postoperatively. He was commenced on oral prednisolone 1mg/kg and oral albendazole 400 mg for 28 days. Conclusion: Cysticercosis should be considered in cases of inflammatory swelling of subconjunctival space especially in people with poor personal and community hygiene. DOI: http://dx.doi.org/10.3126/hren.v11i3.9659 Health Renaissance 2013;11(3):293-296

Medpor Implant Fixation Using Fibrin Glue in Blowout Fracture Surgery

The Medpor implant is (Prous polyethylene, Porex Surgical Inc, Newnan, GA, USA) widely used to reconstruct orbital wall defects. However, this implant is commonly associated with numerous complications, including implant displacement. Therefore, the authors have hypothesized that fixation of the Medpor implant with fibrin glue (Tisseel, Baxter Healthcare, Norfolk, UK), compared to other fixation methods, may be more stable and could provide better results than other fixation methods.In this study, 485 patients who had been treated for blowout fractures from 2008 to 2012 were evaluated. Medpor implants fixed using Tisseel were used to reconstruct bone defects of the orbital wall. The patients' hospital records and radiologic images were reviewed according to sex, fracture site, and postoperative complications.According to retrospective chart review and radiologic evaluation, the complication rate was low and included diplopia (7%; 33 patients), enophthalmos (4%; 17 patients), and extraocular movement limitation (3%; 13 patients).This study suggests that Medpor implant fixation using Tisseel is a simpler, more secure, and more suitable for reconstruction of the fractured orbital wall compared with other methods.

An Analysis of Pure Blowout Fractures and Associated Ocular Symptoms

Blowout fractures are one of the commonly occurring facial bone fractures and clinically important, as they may cause serious complications such as diplopia, extraocular movement limitation, and enophthalmos. The purpose of this study was to evaluate the current patient demographics and surgical outcomes of 952 pure blowout fractures from 2 hospitals of the Catholic University of Korea, from 2003 to 2011. The medical records were reviewed according to the cause, fracture site, ocular symptoms, time of operation, and sequela. Male patients outnumbered female patients, and blowout fractures were most often seen in 21- to 30-year-old men. The most common cause was violent assault (40.7%). The medial orbital wall (45.8%) was the most common site, followed by floor (29.4%) and inferomedial wall (24.6%). The most common ocular injury was hyphema. Diplopia was presented in 27.6%; extraocular movement limitation was detected in 12.8% patients, and enophthalmos was encountered in 3.4% patients. Diplopia, extraocular movement limitation, and enophthalmos were significantly improved by surgical repair (P < 0.05). Postoperative complications were persistent diplopia (1.6%) and enophthalmos (0.4%). We surveyed a large series of blowout fracture in the Republic of Korea and recommend this study to serve as an important guideline in treating pure blowout fractures.

Indirect Carotid-Cavernous Fistula Presenting With Unilateral Ptosis, Limitation of Extraocular Movements, Proptosis, and Conjunctival Injection

A 72-year-old woman awoke with double vision. Her physical examination revealed partial ptosis (Figure 1A); limitation of upgaze (Figure 1B), downgaze (Figure 1C), lateral gaze (Figure 1C), and medial gaze (Figure 1D); conjunctival injection (Figure 1E); and proptosis of the right eye. Computed tomography angiogram demonstrated an indirect carotid-cavernous fistula that was supplied by branches of the internal and external carotid arteries (Barrow D) and drained via superior ophthalmic, facial, and frontal cortical veins (Figure 1F). Given the risk of vision loss and intracerebral hemorrhage from retrograde cortical venous drainage,1 endovascular embolization was performed. One day following this, her conjunctival injection and double vision had improved (Figure 1G). Figure 1. Photographs of patient's extraocular examination prior to treatment demonstrating ptosis, gaze palsy, and conjunctival injection (A-E), computed tomography angiogram revealing dilated right superior ophthalmic and facial veins due to arteriovenous shunting ...

Neglected primary Ewing′s sarcoma of ethmoid presenting as surgical emergency

We present a male child with primary Ewing's sarcoma arising from ethmoid sinuses with intradural and extracranial extension (bilateral nasal cavities, orbits, and maxillary sinuses). This is a rare condition. He presented with recurrent episodes of epistaxis for 2 years, sudden onset rapidly progressive bilateral proptosis, with painful restriction of extraocular movements, and decreased visual acuity for 4 days. Sudden complete loss of vision following admission demanded emergency tumor decompression.