Case #16 (06-03-2004)

[Andrew_Doan]

---

Members do not see this ad.

CC: 89 y.o. woman with a history of gradual redness and proptosis OD over 3 weeks.

HPI: Redness and proptosis OD worsened on 10 days of IV vancomycin & ceftriaxone.

PMH/FH/POH: mitral valve regurgitation, advanced Alzheimer's disease, heart disease, glaucoma, schizophrenia, diabetes, and myopia.

Patient has had trabeculectomies OD and OS.

EXAM
Best corrected visual acuities: NLP OD and 20/125 OS.
Pupils: large RAPD OD by reverse
Confrontational VF: unable to assess
EOM: underaction in all directions of gaze OD.
IOP: 29 mmHg OD, 8 mmHg OS
Anterior segment: see photos, OS normal.
DFE: no view OD, OS normal.
Hertel: 16 mm OD, 10 mm OS (marked proptosis OD)

Half face photograph

Right Eye

Feel free to discuss the following:

What tests should you order (I'll post labs when asked for them)?

What's the differential diagnosis?

What's the diagnosis?

What is the treatment of choice, surgically and/or medically?

 

[Richard_Hom]

CC: 89 y.o. woman with a history of gradual redness and proptosis OD over 3 weeks.

HPI: Redness and proptosis OD worsened on 10 days of IV vancomycin & ceftriaxone.

PMH/FH/POH: mitral valve regurgitation, advanced Alzheimer's disease, heart disease, glaucoma, schizophrenia, diabetes, and myopia.

Patient has had trabeculectomies OD and OS.

EXAM
Best corrected visual acuities: NLP OD and 20/125 OS.
Pupils: large RAPD OD by reverse
Confrontational VF: unable to assess
EOM: underaction in all directions of gaze OD.
IOP: 29 mmHg OD, 8 mmHg OS
Anterior segment: see photos, OS normal.
DFE: no view OD, OS normal.
Hertel: 16 mm OD, 10 mm OS (marked proptosis OD)

Half face photograph

Right Eye

Feel free to discuss the following:

What tests should you order (I'll post labs when asked for them)?

What's the differential diagnosis?

What's the diagnosis?

What is the treatment of choice, surgically and/or medically?

Mutliple problems?
1. Imaging such as CT for a fistula of one of the sinuses or a mass protruding through the optic canal.
2. Neovascular glaucoma "snuff out" of the optic nuerve head.
3. There looks like an extrusion of "orbital fat" or some type enlargement of the lacrimal gland. in OD temporal.
4. B-Scan for total RD

Richard_Hom

 

[cpw]

my first thought was sinus fistula.

I would also like some kind of CT for orbital/sinus mass.

But honestly, if this walked into my office, i'd be calling my good friend Andrew and watching over his shoulder 😛

 

[shredhog65]

i would like a CT orbitsl CT or MRI. Possibly arteriography if no fistula is found.
CBC may be of some use
vitals would be nice

differential includes:

*cavernous fistula - low flow more likely, but high flow still possible
*orbital psuedotumor
*very rapidly enlarging orbital tumor (i wouldn't put my money on this)
*i was going to add orbital cellulitis but i just noticed that the patient had been on ABX for over a week. i guess massive subperiosteal abcess is still possible but highly unlikely


if this is a cavernous fistula (which i think it is) then embolization of the fistula is necessary. first admit the patient. i am assuming that you would want an IR consultation for this. Ligation is possible also, but i would go with embolization.

the treatment for orbital pseudotumor is oral steroids
orbital tumors must be treated once a tissue type is obtained.

 

[Andrew_Doan]

Axial CT of orbits without contrast

Axial CT of orbits without contrast

 

[Andrew_Doan]

I haven't had the time to finish this case presentation yet. Any interpretations on the CT scans and ideas in regards to the next step in management?

 

[JZ2020]

The CT scan images don't show any clear evidence of a mass. The right globe is about twice the size of the left globe, and the right eye has thickened walls with increased enhancement. I also think that the aqueous and vitreous fluid in the right eye appears more dense than in the left eye.
These findings, together with the photos of her face showing pus oozing from the right eye, point towards an infectious etiology. Most likely, the source of infection stems from her trab OD.
The fact that she has shown no improvement on IV Vanco and Rocephin indicates that we are probably dealing with a significant endophthalmitis which will require intravitreal antibiotics and/or surgical intervention (removal of bleb vs. enucleation).

 

[Andrew_Doan]

These findings, together with the photos of her face showing pus oozing from the right eye, point towards an infectious etiology. Most likely, the source of infection stems from her trab OD.
The fact that she has shown no improvement on IV Vanco and Rocephin indicates that we are probably dealing with a significant endophthalmitis which will require intravitreal antibiotics and/or surgical intervention (removal of bleb vs. enucleation).

Exactly.

This patient had an anterior chamber full of inflammatory cells and the eye looked infected. The CT scan showed an area of possible abscess formation. We took this patient to the OR to explore the orbit and globe for an abscess. We found that the patient likely had a pan-endophthalmitis with globe perforation (from the infection) and required enucleation.

Area of globe perforation from pan-endophthalmitis.

Optic nerve separated from the globe during surgery. If you look closely, there is a rim of necrotic appearing tissue.

I'll post here when the final case presentation is posted on www.eyerounds.org

 

[Andrew_Doan]

http://webeye.ophth.uiowa.edu/eyeforum/case16.htm