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 OS VA (n sc): 20/20 20/200 Pupils: 4  2 7 fixed (-)rAPD IOP: 21mmHg 21-26mmHg EOM: -3 -1 -2 -4

Objective PLE: External/Lids Severe edema and ecchymosis, poor view OS. Sutured laceration below left lower eyelid Conj/Sclera Severe chemosis with subconj hem OS Cornea Clear OU Ant Chamber Formed, no gross hyphema Iris Dilated, fixed OS Lens Clear OU Vitreous Poor view OS

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

CT Face Review of the patients CT face demonstrated multiple fractures of the left orbit: comminuted depressed fracture of the floor, medial wall and a minimally displaced fracture of the roof. A fracture of the right inferior orbital rim extending along the anterior wall of the maxillary sinus was also noted. The globes, extraocular muscles, optic nerves, and retroconal fat were intact. Periorbital soft tissue swelling and left orbital emphysema is noted, but no foreign body was reported or appreciated.

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 Limited view (-)rAPD IOP: 20mmHg 16-22mmHg EOM: -3 -2

Objective PLE: External/Lids Severe edema and ecchymosis, poor view OS Conjunctiva/Sclera +2 Injection OS Cornea Dense corneal ulcer, 25% area OS Ant Chamber Formed, limited view OS Iris Limited view OS Lens No view OS Vitreous 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 Plan Corneal ulcer culture Fortified topical antibiotics Vancomycin/Tobramycin MRI orbits - Stat

MRI Orbits Coronal T1 Axial T1 Axial T2 Cellulitis with two flid collections

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

Measuring HU in Our Case 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 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

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