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Grand Rounds Conference Juan P. Fernandez de Castro, MD University of Louisville Department of Ophthalmology and Visual Sciences November 21, 2014.

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Presentation on theme: "Grand Rounds Conference Juan P. Fernandez de Castro, MD University of Louisville Department of Ophthalmology and Visual Sciences November 21, 2014."— Presentation transcript:

1 Grand Rounds Conference Juan P. Fernandez de Castro, MD University of Louisville Department of Ophthalmology and Visual Sciences November 21, 2014

2 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.

3 POH: unremarkable PMHx: unremarkable Family Hx: unremarkable Allergies: NKDA Meds: None RoS: Negative except for positives in HPI Past History

4 IOP:21mmHg21-26mmHg EOM: Objective OD OS OD OS VA (n sc):20/2020/200 Pupils: 4  27 fixed 00 0 0 -3 -2 -4 (-)rAPD

5 Objective PLE: External/LidsSevere edema and ecchymosis, poor view OS. Sutured laceration below left lower eyelid Conj/ScleraSevere chemosis with subconj hem OS CorneaClear OU Ant ChamberFormed, no gross hyphema IrisDilated, fixed OS LensClear OU VitreousPoor view OS

6 Objective DFE: OD: Macula, vessels and periphery WNL OS: No view due to poor cooperation and limited viewing window

7 CT Face

8 Assessment 20 yo male with multiple left orbital fractures, optic nerve and globe intact. No signs of muscle entrapment or retrobulbar hematoma 20 yo male with multiple left orbital fractures, optic nerve and globe intact. No signs of muscle entrapment or retrobulbar hematoma Plan Plan ENT managing fractures. Will reassess as outpatient ENT managing fractures. Will reassess as outpatient Follow up with ophthalmology in 3 days for complete exam Follow up with ophthalmology in 3 days for complete exam

9 1 week After MVA Missed follow up Now returns to clinic because of increased edema of the left periorbital area

10 IOP:20mmHg16-22mmHg EOM: Objective Limited exam due to marked left periorbital edema OD OS OD OS VA (n sc):20/20CF @1ft (↓ from 20/200) Pupils: 3  2 Limited view 00 0 0 -3-2 -2 -3 (-)rAPD

11 Objective PLE: External/LidsSevere edema and ecchymosis, poor view OS Conjunctiva/Sclera+2 Injection OS CorneaDense corneal ulcer, 25% area OS Ant ChamberFormed, limited view OS IrisLimited view OS LensNo view OS VitreousNo view OS

12 Objective DFE: OD: Macula, vessels and periphery WNL OS: Eyelids and corneal ulcer blocking view

13 External Appearance

14 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 DDx Carotid-Cavernous fistula Carotid-Cavernous fistula Orbital abscess Orbital abscess Plan Plan Corneal ulcer culture Corneal ulcer culture Fortified topical antibiotics Fortified topical antibiotics Vancomycin/Tobramycin Vancomycin/Tobramycin MRI orbits - Stat MRI orbits - Stat

15 Axial T1Axial T2 MRI Orbits Coronal T1

16 MRI Orbital cellulitis with discrete loculated peripherally enhancing fluid collections located adjacent to the OS 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 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 Extraconal phlegmon is seen along the left lateral orbital wall No CC fistula No CC fistula

17 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. 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 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. 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. ENT consulted. Suspected source for orbital cellulitis is a coexisting sinusitis.

18 Plan Admit Admit Purulent discharge culture Purulent discharge culture IV antibiotics IV antibiotics Modest, slow improvement in 48 hours Modest, slow improvement in 48 hours Taken to the OR Taken to the OR ENT: Left endoscopic maxillary antrostomy and sphenoidotomy ENT: Left endoscopic maxillary antrostomy and sphenoidotomy Ophthalmology: exploration of left orbit Ophthalmology: exploration of left orbit

19 Intra-operative

20 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

21 Postoperative Cultures from cornea and orbit (x2) positive for Cedecea. Cultures from cornea and orbit (x2) positive for Cedecea. Antibiotic regimen changed according to susceptibilities and Infectious Diseases recommendations Antibiotic regimen changed according to susceptibilities and Infectious Diseases recommendations Systemic IV Levofloxacin and Meropenem Systemic IV Levofloxacin and Meropenem Topical Ciprofloxacin and Tobramycin Topical Ciprofloxacin and Tobramycin Evolved satisfactorily, was discharged from hospital with PO Ciprofloxacin and same topical treatment Evolved satisfactorily, was discharged from hospital with PO Ciprofloxacin and same topical treatment

22 Follow-up 1 week

23 Case Highlights Orbital cellulitis and corneal ulcer due to Cedecea; first reported case Orbital cellulitis and corneal ulcer due to Cedecea; first reported case Retained wood foreign bodies are challenging to detect in imaging studies Retained wood foreign bodies are challenging to detect in imaging studies

24 Cedecea spp. Enterobacteriaceae family Enterobacteriaceae family Named after CDC (Centers for Disease Control) Named after CDC (Centers for Disease Control) Only 20 reports of human infection with this pathogen Only 20 reports of human infection with this pathogen Never reported in orbital cellulitis or corneal ulcers Never reported in orbital cellulitis or corneal ulcers In this case, Cedecea isolated in corneal culture, initial purulent discharge culture and intraoperative sample In this case, Cedecea isolated in corneal culture, initial purulent discharge culture and intraoperative sample

25 Retained Orbital Foreign Body Clinical suspicion Clinical suspicion Detailed history and mechanism of injury Detailed history and mechanism of injury Sweep the fornices Sweep the fornices Image Image

26 Retained Wooden Foreign Body Wood provides a good medium for bacterial growth due to its porous consistency and organic nature 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 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 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

27 Hounsfield Units (HU) Sir Godfrey Newbold Hounsfield CBE, FRS 1979 Nobel Laureate (1919 - 2004) Image from mc.vanderbilt.edu

28 Limitation Conventional computer monitor displays only 256 shades of gray Image modified from: crashingpatient.com Body Lung Bone

29 Measuring HU in Our Case -960-999 HU -150-250 HU Air Wood -960-999 HU Air

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31 Using a Lung Window

32 Callahan, A B, & Yoon, M K. (2013). Intraorbital foreign bodies: Retrospective chart review and review of literature. International ophthalmology clinics, 53(4), 157-65. 124 Charts identified, 53 were analyzed. Mean Age 37 years (2-64) Males 89% Males 89% vs. Females 11% Composition: Metallic- 66% Wood -15% Glass 11% Plastic 4% Unknown 4%

33 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 Organic material –high infection risk Causing strabismus Causing inflammation Causing inflammation Infection Infection Consider removal of metallic objects regardless. Consider removal of metallic objects regardless. Might preclude an MRI in the future.

34 Summary Detection of intraorbital foreign bodies requires high index of suspicion Detection of intraorbital foreign bodies requires high index of suspicion Obtaining accurate and detailed history is essential Obtaining accurate and detailed history is essential CT scan is the imaging modality of choice CT scan is the imaging modality of choice Meticulous review of the imaging if the physical exam is limited Meticulous review of the imaging if the physical exam is limited Early diagnosis, surgical exploration and extraction positively influence the final outcome Early diagnosis, surgical exploration and extraction positively influence the final outcome

35 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 1982;16:775-8. 3.Akinosoglou K, Perperis A, Siagris D, et al. Bacteraemia due to Cedecea davisae in a patient with sigmoid colon cancer: a case report and brief review of the literature. Diagnostic microbiology and infectious disease 2012;74:303-6. 4.Ismaael TG, Zamora EM, Khasawneh FA. Cedecea davisae's Role in a Polymicrobial Lung Infection in a Cystic Fibrosis Patient. Case reports in infectious diseases 2012;2012:176864. 5.Salazar G, Almeida A, Gomez M. [Cedecea lapagei traumatic wound infection: case report and literature review]. Revista chilena de infectologia : organo oficial de la Sociedad Chilena de Infectologia 2013;30:86-9. 6.Peretz A, Simsolo C, Farber E, Roth A, Brodsky D, Nakhoul F. A rare bacteremia caused by Cedecea davisae in patient with chronic renal disease. The American journal of case reports 2013;14:216-8. 7.Lopez LA, Ibarra BS, de la Garza JA, Rada Fde J, Nunez AI, Lopez MG. First reported case of pneumonia caused by Cedecea lapagei in America. The Brazilian journal of infectious diseases : an official publication of the Brazilian Society of Infectious Diseases 2013;17:626-8. 8.Bae BH, Sureka SB. Cedecea davisae isolated from scrotal abscess. The Journal of urology 1983;130:148-9. 9.Dalamaga M, Pantelaki M, Karmaniolas K, Matekovits A, Daskalopoulou K. Leg ulcer and bacteremia due to Cedecea davisae. European journal of dermatology : EJD 2008;18:204-5. 10.Pande BN, Krysinska-Traczyk E, Prazmo Z, Skorska C, Sitkowska J, Dutkiewicz J. Occupational biohazards in agricultural dusts from India. Annals of agricultural and environmental medicine : AAEM 2000;7:133-9. 11.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. 12.Peterson JJ, Bancroft LW, Kransdorf MJ. Wooden foreign bodies: imaging appearance. AJR American journal of roentgenology 2002;178:557-62. 13.Ho VT, McGuckin JF, Jr., Smergel EM. Intraorbital wooden foreign body: CT and MR appearance. AJNR American journal of neuroradiology 1996;17:134-6. 14.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. 15.Hounsfield GN. Nobel lecture, 8 December 1979. Computed medical imaging. Journal de radiologie 1980;61:459-68. 16.Pyhtinen J, Ilkko E, Lahde S. Wooden foreign bodies in CT. Case reports and experimental studies. Acta radiologica 1995;36:148-51.

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