Transcript Non-Ophthalmic Post-Surgical Blindness

Acute Proptosis
Mark Soontornvachrin, MD
Raghu Mudumbai, MD
Ophthalmology Grand Rounds
August 9, 2007
History
 CC: Right eye swelling
 HPI: 19 y/o F with acutely progressive swelling and
decreased vision OD x 4 days
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Poor historian
Since swimming 5 days PTA, increasing facial pain,
and RE swelling
“Incoherent” per grandfather 1 day PTA
Noted by family to hit herself in the RE several times
while asleep 1 day PTA
Taken to OSH morning of admission and seen by
outside ophthalmology consult
Started on treatment for high IOP OD (90s by TonoPen): Diamox IV, Cosopt, Alphagan
Transferred to HMC for definitive care
History
 POH: No surgery/trauma
 PMH: ADHD, developmental delay
 Meds: Zyprexa, Klonipin
 All: NKDA
 SH: Denies T/E/D; from Arlington, WA
 FH: No ocular disease
 ROS: Subjective fever, HA, malaise
Exam
 Vitals: T 101.2 (at OSH); other VS stable
 External: Prominent R proptosis with
RUL/RLL edema, RUL ptosis
OD
OS
 VA
NLP
20/30
P
3→2
3→2
 TP (5%) 28
12
 EOM
Frozen
Full
+APD OD
Exam
 SLE
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LLL: See previous → WNL
S/C: Hemorrhagic chemosis → WNL
K: Clear OU
AC: D&Q OU
I: WNL OU
L: WNL OU
 NDFE
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No disc swelling/pallor OU
Exam
Questions?
Differential Diagnosis
Differential Diagnosis
 Orbital cellulitis
 Orbital subperiosteal abscess
 Orbital apex syndrome
 Cavernous sinus thrombosis
 Idiopathic orbital inflammation
 Orbital mass/tumor
 Thyroid-associated orbitopathy
Imaging
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Summary
 19 y/o F with acute onset unilateral proptosis
 R NLP, APD, frozen globe
 R pansinusitis
 R orbital cellulitis
 R medial orbital subperiosteal abscess
 R cavernous sinus thrombosis
Differential Diagnosis
 Orbital cellulitis
 Orbital subperiosteal abscess
 Orbital apex syndrome
 Cavernous sinus thrombosis
 Idiopathic orbital inflammation
 Orbital mass/tumor
 Thyroid-associated orbitopathy
Cavernous Sinus: Anatomy
Cavernous Sinus: Anatomy
Cavernous Sinus: Anatomy
Cavernous Sinus: Anatomy
Cavernous Sinus: Anatomy
Cavernous Sinus: Anatomy
Cavernous Sinus: Anatomy
Cavernous Sinus: Anatomy
Cavernous Sinus: Anatomy
 A: ICA
 B: CN III
 C: CN IV
 D: CN VI
 E: CN V1
 F: CN V2
Cavernous Sinus: Tributaries
Cavernous Sinus: Drainage
Cavernous Sinus: Neuroimaging
Cavernous Sinus Thrombosis (CST)
 Thrombophlebitic process affecting the
cavernous sinus
 Most commonly infectious etiology
 Occurs as sequelae of local infection (often
concurrently)
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Orbital cellulitis
Subperiosteal abscess
Orbital abscess
Sinusitis
CST: Pathogenesis
 Cavernous sinuses lack valves; allows bi-
directional spread of infection
 Local spread from infectious source (ie.
infected sinus) via draining veins as
contiguous phlebitis
 Septic emboli from distant source
 Bacterial growth induces thrombosis
 Thrombus acts as good growth medium for
more bacterial growth
CST: Sources of Infection
 Paranasal sinusitis
 Ethmoid
 Sphenoid
 Nasal furunculosis
 Oral/dental infections
 Middle ear infections
 Organisms
 Staphylococcus aureus (70%)
 Streptococcus sp. (20%)
 Gram negatives (5%)
 Rarely fungal (immunocompromised)
CST: Epidemiology
 Typically young adults
 Uncommon, no incidence data
 Fatal prior to antibiotic era (pre-1940s)
 Mortality estimate: 14-79%
 Morbidity estimate: 50%
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Cranial neuropathies
Visual loss
CST: Clinical Presentation
 Time from initial infection to presentation
usually between 1-21 days (average 5-6
days)
 Systemic features (sepsis)
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Headache
Fever
Tachycardia
Hypotension
Mental status changes
CST: Ocular Findings
 Classically unilateral, then bilateral within days
 Venous congestion
Chemosis
 Proptosis
 Retinal vein dilatation
External ophthalmoplegia
 Restriction from orbital venous congestion
 Cranial nerve palsies (CN III, VI, IV)
Ophthalmic anesthesia / maxillary anesthesia
Horner’s syndrome
Visual loss (rare in isolated CST)
 Occlusion of ICA, ophthalmic artery, CRA
 Ischemic optic neuropathy
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CST: Complications
 Intracranial infection
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Meningitis
Encephalitis
Abscess
 Pituitary insufficiency
 Hemorrhagic infarction
 Death
CST: Work-Up
 CBC
 Blood cultures
 Lumbar puncture
 Neuroimaging (CT, MRI)
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Expansion of cavernous sinuses
Convex bowing of lateral wall
Abnormal filling defects
Dilation of superior ophthalmic vein
Dural enhancement of cavernous sinus border
CST: Neuroimaging
CST: Treatment
 Empiric high dose IV antibiotics
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Third generation cephalosporin
Anti-staphylococcal penicillin
Metronidazole
 Continued treatment with IV abx for at least
two weeks after apparent clinical resolution
 Surgical drainage of primary infection sites
 Steroids controversial (except if pituitary
insufficiency)
CST: Treatment
 Anticoagulation
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No consensus for use despite theoretical
rationale
Risks include systemic and intracranial
bleeding
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2 cases of intracranial hemorrhage and 2 cases
of systemic hemorrhage reported in literature
No prospective randomized trials due to rarity
of CST and risk of hemorrhage
CST: Anticoagulation
 Southwick (1986): Retrospective review of 86 case
reports of infectious CST from 1940-1984
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Heparinized patients (n=28)
 Death: 4 (14%)
 Full recovery: 10 (36%)
 Recovery with sequelae: 14 (50%)
Non-heparinized patients (n=58)
 Death 23: (40%)
 Full recovery 15: (26%)
 Recovery with sequelae: 20 (34%)
Differences were statistically significant
Probably confounded by reporting bias
Case Follow-Up
 Ceftriaxone, vancomycin, metronidazole started
 LP and blood cultures did not grow any organisms
 Otolaryngology drained sinuses endoscopically
 IOP remained elevated in mid-30s throughout
hospitalization; VA remained NLP
 Otolaryngology revised previous sinus surgery and
decompressed orbit (medial wall, floor)
 Surgical cultures grew MSSA; abx changed to
nafcillin IV and metronidazole
 Patient discharged with home IV abx for 6 weeks
Case Follow-Up
 Ophthalmology follow-up 1 week after d/c
 Comfortable right eye
 NLP
 Pupil 6 mm, non-reactive, +APD OD
 TA 16 (on Diamox, Alphagan, Cosopt)
 Markedly improved proptosis
 Severely motility restriction in all directions
 Complete RUL ptosis
 Decreased corneal sensation
 Normal anterior and posterior segment exam
Summary
 Suspect cavernous sinus thrombosis in the
setting of acute unilateral proptosis
 Frequent etiologies include sinus and facial
infections
 Concurrent orbital cellulitis and/or orbital apex
syndrome may occur
 IV antibiotics clearly reduce mortality and
need to be started immediately
 Anticoagulation is controversial, but can
consider in cases of clot expansion
References
 Bhatia K, Jones NS. Septic cavernous sinus thrombosis secondary to
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sinusitis: Are anticoagulants indicated? A review of the literature. J
laryngol Otol. 2002;16:667-676
Bilyk JR and Jakobiec FA. Chapter 32: Embryology and anatomy of the
orbit and lacrimal system in Duane’s Ophthalmology (2007)
Cannon ML et al. Cavernous sinus thrombosis complicating sinusitis.
Pediatr Crit Care Med 2004;5(1):86-88
Enbright JR et al. Septic thrombosis of the cavernous sinuses. Arch
Intern Med 2001;161:2671-2676
Pavlovich P et al. Septic thrombosis of the cavernous sinus: Two
different mechanisms. Orbit 2006;25:39-43
Southwick FS et al. Septic thrombosis of the venous dural sinuses.
Medicine. 1986;65:82-106
Watkins LM et al. Bilateral cavernous sinus thromboses and intraorbital
abscesses secondary to Streptococcus milleri. Ophthalmology
2003;110:569-574