Combined Lateral Orbitotomy and Endoscopic Transnasal Orbital Decompression in a Case of Orbital Aspergillosis with Impending Intracranial Invasion

A 64-year-old man with a known history of diabetes and hypertension presented to the Accident and Emergency Department with a 2-day history of sudden decreased vision in the right eye. Temporal arteritis was suspected with an elevated erythrocyte sedimentation rate (71 mm/h), and oral prednisolone was started immediately. Four days later, the patient's right eye vision deteriorated from 0.6 to 0.05, with a grade-4 relative afferent pupillary defect and ophthalmoplegia. Computed tomography showed a contrast-enhancing orbital apex mass in the right orbit abutting the medial and lateral portions of the optic nerve with extension to the posterior ethmoid and sphenoid sinuses. A transethmoidal biopsy was performed which yielded septate hyphae suggestive of Aspergillus infection. Ten days later, the patient's right eye vision further deteriorated to hand movement with total ophthalmoplegia. MRI of the orbit showed suspicion of cavernous sinus thrombosis. A combined lateral orbitotomy and transethmoidal orbital apex drainage and decompression were performed to eradicate the orbital apex abscess. Drained pus cultured Aspergillus. The patient was prescribed systemic voriconazole for a total of 22 weeks. The latest MRI scan, performed 8 months after surgery, showed residual inflammatory changes with no signs of recurrence of the disease. To our knowledge, this is the first case report which describes the use of a combined open and endoscopic approach for orbital decompression and drainage in a case of orbital aspergillosis. We believe the combined approach gives good exposure to the orbital apex, and allows the abscess in this region to be adequately drained.