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

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

5. 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

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

7. 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.

8. 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

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

10. Objective Limited exam due to marked left periorbital edema OD OS
VA (n sc): 20/ (↓ from 20/200)
Pupils: 3  2 Limited view
(-)rAPD
IOP: 20mmHg mmHg
EOM: -3 -2

11. 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

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

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

16. 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

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.
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.

18. 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

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.
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

22. Follow-up 1 week

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

24. 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

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

26. 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

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

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

29. Measuring HU in Our Case
Air HU
Wood HU
Air

31. Using a Lung Window

32. 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),

33. 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),

34. 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

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: Farmer JJ, 3rd, Sheth NK, Hudzinski JA, Rose HD, Asbury MF. Bacteremia due to Cedecea neteri sp. nov. Journal of clinical microbiology 1982;16: 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: 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: 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: 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: 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: Bae BH, Sureka SB. Cedecea davisae isolated from scrotal abscess. The Journal of urology 1983;130: 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: 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: 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: Peterson JJ, Bancroft LW, Kransdorf MJ. Wooden foreign bodies: imaging appearance. AJR American journal of roentgenology 2002;178: Ho VT, McGuckin JF, Jr., Smergel EM. Intraorbital wooden foreign body: CT and MR appearance. AJNR American journal of neuroradiology 1996;17: 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:W Hounsfield GN. Nobel lecture, 8 December Computed medical imaging. Journal de radiologie 1980;61: Pyhtinen J, Ilkko E, Lahde S. Wooden foreign bodies in CT. Case reports and experimental studies. Acta radiologica 1995;36: