2026 Poster Presentations
P032: BEYOND 48 HOURS: SUCCESSFUL SUPERIOR ORBITAL FISSURE DECOMPRESSION AFTER TRAUMATIC SPHENOID WING DISLOCATION
Eric M Cohen, BS1; Alex Tran, DO2; Alec Dallas, BS1; Bryan Clampitt, BS1; Mohammad Hassan A Noureldine, MD, MSc3; Alexander Kueffer, MD, PhD, DMD2; Davide Croci, MD2; 1USF Health Morsani College of Medicine; 2Department of General Surgery, Lakeland Regional Health, Lakeland, Florida, United States; 3Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, Florida, United States
Background: Superior orbital fissure (SOF) compression from lateral orbital trauma and greater sphenoid wing fracture is uncommon but can produce ophthalmoplegia via injury to cranial nerves III, IV, VI, and V1. Transverse fractures across the middle fossa and greater sphenoid wing (GSW) are classically associated with abducens palsy and combined cranial neuropathies, given the nerve’s long, vulnerable intracranial course and proximity to skull-base bony edges. In select patterns, impacted lateral orbital wall fragments encroach upon the orbital apex; early recognition and targeted decompression are vital to preserve vision and function. Rarely, skull-base bone fragments act as penetrating intracranial projectiles, underscoring the need for vascular evaluation and planning in high-energy peri-orbital injuries.
Case Description: A previously healthy 16-year-old male presented after an unhelmeted motorized-scooter crash into a fire hydrant. On arrival he was hemodynamically stable with GCS 15, reporting left peri-orbital pain and blurred vision. Intraocular pressure (IOP) was 32 mmHg with improvement after topical anesthetic. Neuro-ophthalmic exam showed complete left ophthalmoplegia (CN III, IV, VI). Non-contrast CT demonstrated multiple orbital fractures with a dislocated left GSW displaced into the SOF. Additional fractures of the lateral-superior orbital rim and frontal sinus were present. There was no evident optic canal compromise. Diagnostic angiography excluded carotid-cavernous fistula. Given SOF compression and concomitant rim and frontal sinus injuries, operative decompression and reconstruction were indicated. Operative decompression was performed greater than 48 hours after the injury.
Surgical Technique: Under general anesthesia with Mayfield fixation and bicoronal exposure, an interfascial temporalis dissection and left frontotemporal craniotomy were performed. The meningoorbital band was coagulated and divided. The GSW was thinned with a diamond drill and key foramina identified. The SOF was circumferentially compressed by displaced sphenoid fragment; a 3-mm diamond drill and microdissection achieved complete decompression along its length. The concomitant frontal sinus injury was treated as well, the comminuted frontal sinus inner table was removed, mucosa stripped, and the sinus cranialized with layered DuraGen and a vascularized periosteal graft. The lateral orbital rim was reduced and rigidly fixated with matrix plates and screws. The bone flap was replaced and augmented with mesh; meticulous hemostasis was achieved. Plastic surgery repaired the orbital floor. Implants included low-profile CMF plates/screws and dural adjuncts. No intraoperative complications occurred.
Postoperative Course: The patient was extubated in the operating room and transferred in stable condition. Immediate findings included successful SOF decompression and restoration of orbital rim alignment without CSF leak. No operative complications were recorded. Cranial nerve dysfunction fully resolved by one month postoperatively; the patient continues to do well at two years.
Conclusion: SOF compression from a dislocated GSW is a surgically remediable skull-base emergency. While early intervention is ideal, this case demonstrates that targeted SOF decompression can restore function when performed more than 48 hours after trauma. A frontotemporal approach with early SOF decompression, and rigid rim fixation can relieve neurovascular constriction and restore anatomic corridors. High-resolution imaging, angiographic screening are warranted, and multidisciplinary skull-base–oculoplastic collaboration are critical to optimize cranial nerve and visual outcomes.
