Transcript 2015-7-17-Wooden-Orbit-FB_Apenbrinckx

Grand Rounds
Eddie Apenbrinck M.D.
University of Louisville School of Medicine
Department of Ophthalmology & Visual Sciences
7/17/2015
Subjective
CC: right eye pain and decreased vision
HPI: 76 year old white male transferred from outside
hospital (OSH) 5 days after being struck in right
orbit with a tree branch while using a hand saw.
Initially, the patient denied any ocular pain or visual
acuity changes but developed progressive
periorbital edema, pain, and decreased vision
starting 1 day after the injury.
Course prior to admission

Patient initially seen by an optometrist (1 day after
initial incident) and treated with an unknown topical
antibiotic drops for presumed preseptal cellulitis

When symptoms worsened patient was seen by a
ophthalmologist and admitted for IV antibiotics
(Vancomycin and Zosyn) for orbital cellulitis

During admission orbital CT scan showed right
orbital foreign body
POH: presbyopia
PMHx: hypertension, nephrolithiasis, depression, anxiety
ROS: negative
Medications: Azor, Citalopram, Lorazepam
Allergies: NKDA
Social: social alcohol, denies cigarettes or illicits
Exam
OD
OS
VA(cc, near):
20/200-1
20/20
Pupils:
4
4
2
2
1+RAPD OD
IOP:
EOM
20
14
0
-3
-3
-2
-3
0
0
0
Exam
OD
OS
Anterior Segment
L/L
Proptosis, edema
entrance wound upper eyelid
Mucopurulent drainage
C/S:
Cornea:
AC:
I/L:
Vitreous:
DFE:
WNL
WNL OU
WNL OU
No cell or flare OU
WNL OU
WNL OU
WNL OU
Clinical Photo
Clinical Photo
Coronal CT Orbitals
Axial CT Orbitals
Length
Hounsfield Units: -227.00
Assessment and Plan

Assessment:


76 year old white male with orbital foreign body OD and
orbital cellulitis OD
Plan:



Surgery with Oculoplastics for orbit exploration and orbital
foreign body removal
Consult infectious disease for recommendation on
antifungals, antibiotics
Follow up results of blood cultures from OSH
Intraoperative Photo
Intraoperative Photo
Post-Op Day 1
Post-Op day 1
Clinical Course

Temporary tarsorraphy placed OD for
conjunctival chemosis

Continued on IV vancomycin and zosyn per ID
recommendations throughout hospital course

ID recommended against starting amphotericin
B secondary to potential side effects and no
culture proven fungal infection, instead
Fluconazole started for fungal coverage
Clinical Course

Vision and motility slowly improved

Prior to discharge Va OD 20/100

Blood Cultures: Negative

Wood Specimen Cultures: Negative prior to
discharge

Prior to discharge antibiotics switched to oral
Levaquin and Doxycycline
1 week Outpatient Follow-up

Visual acuity stable since discharge




OD: 20/100
Periorbital edema much improved
Motility full OU
Preliminary Fungal cultures growing black mold
Species unknown
 Infectious Disease switched from fluconazole to
voriconazole (6 week course) and arrange follow-up
with ID in Paducah, KY

3 week Outpatient Follow-up

VA:
OD: 20/30
 OS: 20/20


Motility Full OU; no Diplopia

Final Fungal Cultures: Chaetomium species

Continue Voriconazole for 3 more weeks per ID
Chaetomium Genus

A dematiaceous (dark-walled/black) mold
normally found in soil, air, and plant debris.

~95 species in the genus

Grows best between 25°C and 35°C

Per a 2012 article, approximately 20 cases of
chaetomium infection have been reported in the
literature since 1980
Hounsfield Units (HU)
On CT, structures are assigned a Hounsfield
Unit representing their relative density.

Air is assigned a value of -1000, water 0,
and bone +1000

The scale extends in the positive direction
to about +4000, which represents very dense metals.
Sir Godfrey Newbold
Hounsfield CBE, FRS
1979 Nobel Laureate
(1919 - 2004)



Window: the range of Hounsfield units displayed; max=2000
Window Level: the Hounsfield number in the center of the window
width.
Hounsfield Units (HU)

The maximum window width is about 2000 HU,
but the human eye is not capable of seeing this
many shades of gray

The human eye can only distinguish about 16
shades of gray. The window width is divided by
16, and each group of Hounsfield values is
converted to one of 16 shades of gray.
Retained Orbital Wooden Foreign Body

Detailed history, clinical suspicion, complete eye
exam, imaging (CT) with analysis of hounsfeld
units

Wood provides a good medium for bacterial
and fungal growth due to its porous consistency
and organic nature

Heterogeneous low density that makes it
difficult to detect on CT and MRI, mimicking air
 44 year old male diagnosed with fungal keratitis confirmed to by
Chaetomium atrobrunneum by PCR
 Required dual anti-fungal treatment with natamycin 5% and oral
ketoconazole
 65-year-old woman who presented with a corneal ulcer with
hypopyon of the right eye with a history of trauma by vegetable
matter.
 Treated with hourly natamycin 5% and ulcer resolved after 4 weeks
References
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P. K. Balne, S. Nalamada, M. Kodiganti, and M. Taneja, “Fun- gal keratitis caused by
Chaetomium atrobrunneum,” Cornea, vol. 31, no. 1, pp. 94–95, 2012.
Prabhu SM, Irodi A, George PP, Sundaresan R, Anand V. Missed intranasal wooden
foreign bodies on computed tomography. The Indian journal of radiology & imaging
2014;24:72-4.
Peterson JJ, Bancroft LW, Kransdorf MJ. Wooden foreign bodies: imaging
appearance. AJR American journal of roentgenology 2002;178:557-62.
Ho VT, McGuckin JF, Jr., Smergel EM. Intraorbital wooden foreign body: CT and
MR appearance. AJNR American journal of neuroradiology 1996;17:134-6.
Jarraya M, Hayashi D, de Villiers RV, et al. Multimodality imaging of foreign bodies
of the musculoskeletal system. AJR American journal of roentgenology
2014;203:W92-102.
Hounsfield GN. Nobel lecture, 8 December 1979. Computed medical imaging.
Journal de radiologie 1980;61:459-68.
Pyhtinen J, Ilkko E, Lahde S. Wooden foreign bodies in CT. Case reports and
experimental studies. Acta radiologica 1995;36:148-51.