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Peer-reviewedCC BY-NC-NDBMC ophthalmology

Orbital apex syndrome caused by imaging-occult sphenoid sinus fungal infection and the necessity of early surgical exploration: a retrospective case series.

  • Zhixing Li1
  • Weibin Liu1
  • Yanchen Zhang1
  • Wencan Wu2,3,4
  • Yunhai Tu5,6,7
  • Jieliang Shi8,9,10
10 affiliations
  1. 1State Key Laboratory of Eye Health, Eye Hospital, Wenzhou Medical University, 270 Xueyuan West Road, Wenzhou, Zhejiang, 325027, China.
  2. 2State Key Laboratory of Eye Health, Eye Hospital, Wenzhou Medical University, 270 Xueyuan West Road, Wenzhou, Zhejiang, 325027, China. [email protected].
  3. 3Zhejiang Key Laboratory of Key Technologies for Visual Pathway Reconstruction, Wenzhou, 325027, China. [email protected].
  4. 4National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, 325027, China. [email protected].
  5. 5State Key Laboratory of Eye Health, Eye Hospital, Wenzhou Medical University, 270 Xueyuan West Road, Wenzhou, Zhejiang, 325027, China. [email protected].
  6. 6Zhejiang Key Laboratory of Key Technologies for Visual Pathway Reconstruction, Wenzhou, 325027, China. [email protected].
  7. 7National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, 325027, China. [email protected].
  8. 8State Key Laboratory of Eye Health, Eye Hospital, Wenzhou Medical University, 270 Xueyuan West Road, Wenzhou, Zhejiang, 325027, China. [email protected].
  9. 9Zhejiang Key Laboratory of Key Technologies for Visual Pathway Reconstruction, Wenzhou, 325027, China. [email protected].
  10. 10National Clinical Research Center for Ocular Diseases, Eye Hospital, Wenzhou Medical University, Wenzhou, 325027, China. [email protected].
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Abstract

Objective

To characterize a highly occult subtype of sphenoid invasive fungal rhinosinusitis (IFRS) presenting as acute orbital apex syndrome (OAS) without classic invasive imaging signs, and to evaluate the efficacy of early surgical intervention.Methods

This retrospective case series evaluated six patients (March 2021-November 2025) who developed classic OAS secondary to sphenoid IFRS despite strictly subtle imaging manifestations. All underwent navigation-guided endoscopic sinus clearance and optic nerve decompression. Pre- and postoperative neuro-ophthalmic parameters (best-corrected visual acuity [BCVA], visual field index [VFI], mean deviation [MD], and ocular motility) were analyzed. Bias-corrected effect sizes (Hedges' g) were calculated to quantify the magnitude of functional recovery.Results

Pathological evaluation confirmed Aspergillus fumigatus (n=4), Penicillium citrinum (n=1), and Rhizopus oryzae (n=1). Four patients (66.7%) had comorbid type 2 diabetes. Following surgery, median BCVA improved from 1.91 to 0.30 LogMAR (Hedges' g = 0.80). In the four patients completing visual field testing, median VFI improved from 11% to 91.5% (g = 1.37), and median MD improved from -28.02 to -3.33 dB (g = 1.23). Ocular motility fully recovered in two of three affected patients. Notably, the two patients lacking visual recovery presented with severe preoperative hyperglycemia (>14 mmol/L). No severe surgery-related complications occurred.Conclusions

For occult IFRS presenting with this striking 'clinical-radiological dissociation', early navigation-guided endoscopic exploration is a crucial sight-saving strategy. Strict glycemic control is paramount to preserving this therapeutic window. Further prospective validation is warranted.

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Cite

BibTeXRIS
BibTeX
@article{li2026orbital,
  title = {{Orbital apex syndrome caused by imaging-occult sphenoid sinus fungal infection and the necessity of early surgical exploration: a retrospective case series.}},
  author = {Zhixing Li and Weibin Liu and Yanchen Zhang and Wencan Wu and Yunhai Tu and Jieliang Shi},
  journal = {BMC ophthalmology},
  year = {2026},
  month = aug,
  doi = {10.1186/s12886-026-05170-4},
  url = {https://europepmc.org/article/MED/42968036},
  note = {CC BY-NC-ND},
}
RIS
TY  - JOUR
TI  - Orbital apex syndrome caused by imaging-occult sphenoid sinus fungal infection and the necessity of early surgical exploration: a retrospective case series.
AU  - Zhixing Li
AU  - Weibin Liu
AU  - Yanchen Zhang
AU  - Wencan Wu
AU  - Yunhai Tu
AU  - Jieliang Shi
PY  - 2026
DA  - 2026/08/05
JO  - BMC ophthalmology
DO  - 10.1186/s12886-026-05170-4
UR  - https://europepmc.org/article/MED/42968036
AB  - Objective  To characterize a highly occult subtype of sphenoid invasive fungal rhinosinusitis (IFRS) presenting as acute orbital apex syndrome (OAS) without classic invasive imaging signs, and to evaluate the efficacy of early surgical intervention.Methods  This retrospective case series evaluated six patients (March 2021-November 2025) who developed classic OAS secondary to sphenoid IFRS despite strictly subtle imaging manifestations. All underwent navigation-guided endoscopic sinus clearance and optic nerve decompression. Pre- and postoperative neuro-ophthalmic parameters (best-corrected visual acuity [BCVA], visual field index [VFI], mean deviation [MD], and ocular motility) were analyzed. Bias-corrected effect sizes (Hedges' g) were calculated to quantify the magnitude of functional recovery.Results  Pathological evaluation confirmed Aspergillus fumigatus (n=4), Penicillium citrinum (n=1), and Rhizopus oryzae (n=1). Four patients (66.7%) had comorbid type 2 diabetes. Following surgery, median BCVA improved from 1.91 to 0.30 LogMAR (Hedges' g = 0.80). In the four patients completing visual field testing, median VFI improved from 11% to 91.5% (g = 1.37), and median MD improved from -28.02 to -3.33 dB (g = 1.23). Ocular motility fully recovered in two of three affected patients. Notably, the two patients lacking visual recovery presented with severe preoperative hyperglycemia (>14 mmol/L). No severe surgery-related complications occurred.Conclusions  For occult IFRS presenting with this striking 'clinical-radiological dissociation', early navigation-guided endoscopic exploration is a crucial sight-saving strategy. Strict glycemic control is paramount to preserving this therapeutic window. Further prospective validation is warranted.
SN  - 1471-2415
ER  -