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Management of Lesions at the Cranioorbital Junction

Lesions in the vicinity of the cranioorbital junction can present with a variety of neurological and ophthalmic symptoms, depending on their anatomical location, size, growth pattern, and duration. However, in general, once a lesion reaches the cranioorbital junction, a recognizable pattern of ophthalmic findings appears. Because of the crowding of cranial nerves that occurs at the orbital apex, the superior orbital fissure, and the cavernous sinus, patients usually present with an external ophthalmoplegia involving more than one cranial nerve. Previous descriptions of the so-called orbital apex syndrome, cavernous sinus syndrome, and superior orbital fissure syndrome depend on a lesion of relatively small size occupying a specific location of the cranioorbita1 junction. As an example, because the second division of the trigeminal nerve lies adjacent to the posterior cavernous sinus as it exits through the foramen rotundum, it may be affected by a lesion in the posterior cavernous sinus but is spared in superior orbital fissure syndrome. These subtle differences in presentation are often not reliable indicators of location and were perhaps more useful in the past, before neuroimaging was readily available. The clinical constellation (Fig 1) associated with mass lesions of the cranioorbital junction is more practically described by Walsh and Hoyt as the “sphenocavernous syndrome” [ 13 or by other authors as the “parasellar syndrome” [2]. Involvement of the third, fourth, and sixth cranial nerves is typical. The first division of the trigeminal nerve is also usually affected,