1. Grand Rounds Eddie Apenbrinck M.D. University of Louisville School of Medicine Department of Ophthalmology & Visual Sciences 7/17/2015

2. 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.

3. 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 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 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 During admission orbital CT scan showed right orbital foreign body

4. POH: presbyopia PMHx: hypertension, nephrolithiasis, depression, anxiety ROS: negative Medications: Azor, Citalopram, Lorazepam Allergies: NKDA Social: social alcohol, denies cigarettes or illicits

5. Exam OD OS VA(cc, near): 20/200-1 20/20 Pupils: 4 2 4 2 1+RAPD OD IOP: 20 14 EOM 00 0 0 -3-2 -3 -3

6. Exam OD OS Anterior Segment L/LProptosis, edemaWNL entrance wound upper eyelid Mucopurulent drainage C/S:WNLOU Cornea:WNLOU AC: No cell or flare OU I/L: WNLOU Vitreous: WNLOU DFE: WNL OU

7. Clinical Photo

9. Coronal CT Orbitals

10. Axial CT Orbitals Hounsfield Hounsfield Units: -227.00Length

11. Assessment and Plan Assessment: Assessment: 76 year old white male with orbital foreign body OD and orbital cellulitis OD Plan: Plan: Surgery with Oculoplastics for orbit exploration and orbital foreign body removal Surgery with Oculoplastics for orbit exploration and orbital foreign body removal Consult infectious disease for recommendation on antifungals, antibiotics Consult infectious disease for recommendation on antifungals, antibiotics Follow up results of blood cultures from OSH Follow up results of blood cultures from OSH

12. Intraoperative Photo

14. Post-Op Day 1

15. Post-Op day 1

16. Clinical Course Temporary tarsorraphy placed OD for conjunctival chemosis Temporary tarsorraphy placed OD for conjunctival chemosis Continued on IV vancomycin and zosyn per ID recommendations throughout hospital course 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 ID recommended against starting amphotericin B secondary to potential side effects and no culture proven fungal infection, instead Fluconazole started for fungal coverage

17. Clinical Course Vision and motility slowly improved Vision and motility slowly improved Prior to discharge Va OD 20/100 Prior to discharge Va OD 20/100 Blood Cultures: Negative Blood Cultures: Negative Wood Specimen Cultures: Negative prior to discharge Wood Specimen Cultures: Negative prior to discharge Prior to discharge antibiotics switched to oral Levaquin and Doxycycline Prior to discharge antibiotics switched to oral Levaquin and Doxycycline

18. 1 week Outpatient Follow-up Visual acuity stable since discharge Visual acuity stable since discharge OD: 20/100 OD: 20/100 Periorbital edema much improved Periorbital edema much improved Motility full OU Motility full OU Preliminary Fungal cultures growing black mold Preliminary Fungal cultures growing black mold Species unknown Species unknown Infectious Disease switched from fluconazole to voriconazole (6 week course) and arrange follow-up with ID in Paducah, KY Infectious Disease switched from fluconazole to voriconazole (6 week course) and arrange follow-up with ID in Paducah, KY

19. 3 week Outpatient Follow-up VA: VA: OD: 20/30 OD: 20/30 OS: 20/20 OS: 20/20 Motility Full OU; no Diplopia Motility Full OU; no Diplopia Final Fungal Cultures: Chaetomium species Final Fungal Cultures: Chaetomium species Continue Voriconazole for 3 more weeks per ID Continue Voriconazole for 3 more weeks per ID

20. 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

21. 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. Window: the range of Hounsfield units displayed; max=2000 Window Level: the Hounsfield number in the center of the window width. Sir Godfrey Newbold Hounsfield CBE, FRS 1979 Nobel Laureate (1919 - 2004)

22. 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.

23. Retained Orbital Wooden Foreign Body Detailed history, clinical suspicion, complete eye exam, imaging (CT) with analysis of hounsfeld units 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 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 Heterogeneous low density that makes it difficult to detect on CT and MRI, mimicking air

24.  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

25. References 1. 1. 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. 2. 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. 3. Peterson JJ, Bancroft LW, Kransdorf MJ. Wooden foreign bodies: imaging appearance. AJR American journal of roentgenology 2002;178:557-62. 4. Ho VT, McGuckin JF, Jr., Smergel EM. Intraorbital wooden foreign body: CT and MR appearance. AJNR American journal of neuroradiology 1996;17:134-6. 5. 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. 6. Hounsfield GN. Nobel lecture, 8 December 1979. Computed medical imaging. Journal de radiologie 1980;61:459-68. 7. Pyhtinen J, Ilkko E, Lahde S. Wooden foreign bodies in CT. Case reports and experimental studies. Acta radiologica 1995;36:148-51.