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A 21-month-old male presented with a low impact fall striking his left eye against a metal stand at the market. On examination he was in no distress, had significant periorbital swelling, a dilated pupil with a sluggish pupillary response, and grossly normal extraocular movements. The initial orbital computed tomography (CT) showed a small nondisplaced fracture of the orbital roof with a fracture around the orbital apex. There was loculated air and hemorrhage within the left orbit, but the globe was intact. There was also an abnormal dense intracranial calcification along the lateral margin of the suprasellar region near the cavernous sinus which was suspicious for a small fracture fragment (Figure 1). A head CT confirmed the finding of a 4–5mm bone intracranial fragment posterior to the left orbital apex (Figure 2).
The orbital apex is the most posterior third of the conical orbit and contains the optic canal, superior orbital fissure, and neurovascular structures.1 Fracture of the orbital apex has been shown to result from high-energy trauma.2 They seldom occur as isolated, low impact events, such as in our patient’s case. There are many potential complications involved with orbital apex fractures, including injury to the optic nerve, superior orbital fissure syndrome, and orbital apex syndrome.1 The orbital apex involves complex osseous anatomic structures and intimately encloses neurovascular organs that are at risk for permanent damage in an orbital apex fracture. Optic nerve injury may result in loss of visual acuity or immediate blindness. In pediatric patients with head trauma involving the eye, it is imperative to keep in mind the possibility of orbital apex fractures as a potential source of optic nerve damage even in the presence of a low impact injury.
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