Transcript Grand Rounds - University of Louisville Ophthalmology

Grand Rounds Conference
Juan P. Fernandez de Castro, MD
University of Louisville
Department of Ophthalmology and Visual Sciences
November 21, 2014
Subjective
CC: Called by ER to rule out globe injury
HPI: 20 yo male, presented to an outside ER after
an unrestrained MVA. After complete trauma
survey, including a CT of the face that showed
multiple fractures of the left orbit the patient
was transferred to our institution for further
management.
Eye swollen shut since the accident. Tolerable
pain, not altered by eye movements. Denies
flashes.
Past History
POH: unremarkable
PMHx: unremarkable
Family Hx: unremarkable
Allergies: NKDA
Meds: None
RoS: Negative except for positives in HPI
Objective
OD
20/20
42
VA (n sc):
Pupils:
IOP:
EOM:
(-)rAPD
OS
20/200
7 fixed
21mmHg
21-26mmHg
0
-3
0
0
0
-4
-1
-2
Objective
PLE:
External/Lids
Conj/Sclera
Cornea
Ant Chamber
Iris
Lens
Vitreous
Severe edema and ecchymosis,
poor view OS. Sutured laceration below
left lower eyelid
Severe chemosis with subconj hem OS
Clear OU
Formed, no gross hyphema
Dilated, fixed OS
Clear OU
Poor view OS
Objective
DFE:
OD: Macula, vessels and periphery WNL
OS: No view due to poor cooperation and
limited viewing window
CT Face
Assessment

20 yo male with multiple left orbital fractures,
optic nerve and globe intact. No signs of muscle
entrapment or retrobulbar hematoma

Plan
ENT managing fractures. Will reassess as outpatient
 Follow up with ophthalmology in 3 days for
complete exam

1 week After MVA
Missed follow up
Now returns to clinic because of increased edema
of the left periorbital area
Objective
Limited exam due to marked left periorbital edema
OD
OS
VA (n sc):
20/20
CF @1ft
(↓ from 20/200)
Pupils:
32
IOP:
EOM:
20mmHg
(-)rAPD
Limited view
16-22mmHg
0
-3
0
0
0
-3
-2
-2
Objective
PLE:
External/Lids
Conjunctiva/Sclera
Cornea
Ant Chamber
Iris
Lens
Vitreous
Severe edema and
ecchymosis, poor view OS
+2 Injection OS
Dense corneal ulcer,
25% area OS
Formed, limited view OS
Limited view OS
No view OS
No view OS
Objective
DFE:
OD: Macula, vessels and periphery WNL
OS: Eyelids and corneal ulcer blocking view
External Appearance
Assessment
20 yo male, s/p D7 MVA with left orbital
fractures, now with corneal ulcer OS and out of
proportion left eyelid edema.
 DDx
Carotid-Cavernous fistula
 Orbital abscess
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
Plan
Corneal ulcer culture
 Fortified topical antibiotics



Vancomycin/Tobramycin
MRI orbits - Stat
MRI Orbits
Coronal T1
Axial T1
Axial T2
MRI




Orbital cellulitis with discrete loculated
peripherally enhancing fluid collections located
adjacent to the OS
Significant soft tissue edema, with
heterogeneous enhancement, extending into the
left orbit, with stranding of both the extraconal
and intraconal fat
Extraconal phlegmon is seen along the left
lateral orbital wall
No CC fistula
Other MRI Findings

MRI of the brain (not shown) demonstrates mild
dural enhancement near the apex in the left orbit
with no definite abscess within the cranial space.


Neurosurgery consulted to rule out intracranial
extension. No meningitis, no acute intervention
Opacification of left maxillary and ethmoid
sinuses, as well as some mucosal thickening of
the left sphenoid and frontal sinus.

ENT consulted. Suspected source for orbital cellulitis
is a coexisting sinusitis.
Plan



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Admit
Purulent discharge culture
IV antibiotics
Modest, slow improvement in 48 hours
Taken to the OR
ENT: Left endoscopic maxillary antrostomy and
sphenoidotomy
 Ophthalmology: exploration of left orbit

Intra-operative
Intra-operative
A retained wooden object (1.2 x 0.9 x 0.7 cm) in the temporal aspect of the superior
fornix was identified and removed
Culture obtained from purulent discharge
Postoperative


Cultures from cornea and orbit (x2) positive for
Cedecea.
Antibiotic regimen changed according to
susceptibilities and Infectious Diseases
recommendations
Systemic IV Levofloxacin and Meropenem
 Topical Ciprofloxacin and Tobramycin


Evolved satisfactorily, was discharged from
hospital with PO Ciprofloxacin and same topical
treatment
Follow-up 1 week
Case Highlights

Orbital cellulitis and corneal ulcer due to Cedecea;
first reported case

Retained wood foreign bodies are challenging to
detect in imaging studies
Cedecea spp.





Enterobacteriaceae family
Named after CDC (Centers for Disease
Control)
Only 20 reports of human infection with this
pathogen
Never reported in orbital cellulitis or corneal
ulcers
In this case, Cedecea isolated in corneal culture,
initial purulent discharge culture and
intraoperative sample
Retained Orbital Foreign Body




Clinical suspicion
Detailed history and mechanism of injury
Sweep the fornices
Image
Retained Wooden Foreign Body



Wood provides a good medium for bacterial
growth due to its porous consistency and
organic nature
Heterogeneous low density that makes it
difficult to detect on CT and MRI, mimicking air
On CT in the acute stage wood presents as a low
attenuation area. As it progresses to a chronic
stage it becomes hyperdense because of mineral
deposition
Hounsfield Units (HU)
Sir Godfrey Newbold
Hounsfield CBE, FRS
1979 Nobel Laureate
(1919 - 2004)
Image from mc.vanderbilt.edu
Limitation
Image modified from: crashingpatient.com
Bone
Lung
Body
Conventional computer monitor displays only 256 shades of gray
Measuring HU in Our Case
-960-999 HU Air
-150-250 HU Wood
-960-999 HU Air
Using a Lung Window
124 Charts identified, 53 were analyzed.
• Mean Age 37 years (2-64)
• Males 89% vs. Females 11%
• Composition:
Metallic- 66%
Wood -15%
Glass 11%
Plastic 4%
Unknown 4%
Callahan, A B, & Yoon, M K. (2013). Intraorbital foreign bodies: Retrospective chart review and
review of literature. International ophthalmology clinics, 53(4), 157-65.
• CT is the imaging technique of choice
Notable exception is wood, MRI complementary study
• History and physical examination
• Assess the risk of surgical removal
• Foreign body should be removed if:
• Organic material –high infection risk
• Causing strabismus
• Causing inflammation
• Infection
• Consider removal of metallic objects regardless.
Might preclude an MRI in the future.
Callahan, A B, & Yoon, M K. (2013). Intraorbital foreign bodies: Retrospective chart review and
review of literature. International ophthalmology clinics, 53(4), 157-65.
Summary

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Detection of intraorbital foreign bodies requires
high index of suspicion
Obtaining accurate and detailed history is
essential
CT scan is the imaging modality of choice
Meticulous review of the imaging if the physical
exam is limited
Early diagnosis, surgical exploration and
extraction positively influence the final outcome
References
1.Grimont PAD, Grimont F, Farmer JJ, Asbury MA. Cedecea davisae gen. nov., sp. nov. and Cedecea lapagei sp. nov., New Enterobacteriaceae
from Clinical Specimens. International Journal of Systematic Bacteriology 1981;31:317-26.
2.Farmer JJ, 3rd, Sheth NK, Hudzinski JA, Rose HD, Asbury MF. Bacteremia due to Cedecea neteri sp. nov. Journal of clinical microbiology
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