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Did the needle make me blind?

TEI Grand Ward Round. Did the needle make me blind?. Desmond Quek Resident. History. Mdm CAT, 59yo chinese female PHx DM x10 yrs on OHGA Hypt Hyperlipidemia 10/05/2007 LE pain, swelling, redness, BOV x2/7 Had session of acupuncture a day prior for headache

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Did the needle make me blind?

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  1. TEI Grand Ward Round Did the needle make me blind? Desmond Quek Resident

  2. History • Mdm CAT, 59yo chinese female • PHx • DM x10 yrs on OHGA • Hypt • Hyperlipidemia • 10/05/2007 • LE pain, swelling, redness, BOV x2/7 • Had session of acupuncture a day prior for headache • No other symptoms of chronic sinusitis

  3. Examination • T 37.9ºC, lethargic, toxic • VL: HM; NPL sup & temp PL inf & nasal • Lid erythema, edema, ptosis • Proptosis • Conjunctival injection + chemosis • L RAPD • IOP 38 • EOM 0 -4 0 0 -4 -4 0 -4

  4. Examination • Dilated fundal examination • pale fundus • cherry red spot • V1, VII n intact

  5. Assessment • 59 yo diabetic with • Orbital cellulitis • Secondary to sinusitis/ ? acupuncture • Complicated by • Raised IOP • CRAO • ? Septicaemia

  6. Investigations • FBC • TW 6.4 Hb 12.9 Plt 222 • CRP • 212.6 • Bld C/S • NBG • Eye swab C/S • Wbc + • Gram+ve cocci + • Gram+ve rods ++ • H influenzae • Sensitive to ceftriaone, augmentin, levofloxacin

  7. Investigations • CT orbits/ ant visual pathways

  8. Treatment • Drainage of subperiosteal abscess • 10 - 15 ml haemopurulent fluid • Topical • Cravit • Timolol • ID consult • Initial antibiotics: IV ceftriaxone + cloxacillin • In view of sinusitis: IV clindamycin + tazocin • H influenzae sensitivity: IV augmentin • ENT consult • CT sinuses: frontal and ethmoidal sinusitis • FESS 160507

  9. Progress • Afebrile • VL: PL; NPL nasal & sup PL inf & temp •  Lid erythema, edema •  Proptosis •  Conjunctival injection + chemosis • L RAPD • IOP 10 • EOM 0 -1 0 0 -1 -1 0 -2

  10. Progress • Dilated fundal examination • Pale disc • Pale fundus • Macula edema ++ • Dot & blot haemorrhages 4 quad

  11. Summary • 59 yo diabetic with • Orbital cellulitis & subperiosteal abscess • Secondary to H. influenzae sinusitis • Complicated by • Raised IOP • CRAO • CRVO • Treated by • Drainage of subperiosteal abscess • FESS • Intravenous antibiotics • With resolution of inflammation • Permanent devastating visual loss

  12. Case Report Central retinal artery occlusion following staphylococcal orbital cellulitis R M Bhola, S Dhingra, A G McCormick and T K Chan Ophthalmology Department Royal Hallamshire Hospital Glossop Road Sheffield S10 2JF, UK Eye. 2003 Jan;17(1):109-11.

  13. History & Examination • 51-year-old Indian male • No significant contributory medical history • 24-h history of progressive left periorbital pain and swelling • Accompanied by fever and chills • VR 6/4 and VL HM • LE: • pustular lesion at the inner aspect of the upper lid • periorbital swelling • complete ptosis • marked proptosis • haemorrhagic chemosis

  14. Examination • LE: • corneal oedema • patchy filling of the tributaries of the central retinal artery and vein • superficial retinal opacification at the posterior pole • absence of a cherry red spot at the macula

  15. Management • Intravenous acetazolamide • Ocular massage • Anterior chamber paracentesis • Unsuccessful at restoring retinal perfusion • VL deteriorated to NPL • MRI/ CT: • soft tissue density infiltrate extending anteriorly around the left globe • no sub-periosteal abscess • clear sinuses • no intracranial involvement

  16. Management • C/S pustular lesion • Staphylococcus aureus • Orbital cellulitis responded to IV flucloxacillin and metronidazole • Full blood count • increase in neutrophils and monocytes during the acute illness • Inflammatory markers returning to normal after the infection resolved • Immunological and haematological investigations were all normal

  17. Management • FFA 1 week after confirmed retinal vascular occlusion with normal choroidal perfusion • Six weeks later, fundal examination did NOT demonstrate disturbances in the retinal pigment epithelium consistent with choroidal ischaemia

  18. Comment • Acute arterial occlusion is an unusual but known complication of orbital cellulitis • It has been demonstrated that following orbital inflammation, occlusion may occur at the level of the central retinal arteryor occasionally at the ophthalmic artery • In CRAO, there is typically a cherry red spot at the macula • In this case, there was retinal whitening at the posterior pole • usually seen in ophthalmic artery occlusion

  19. Comment • Interestingly, FFA 1 week after the event demonstrated CRAO but the choroidal perfusion was deemed to be normal. • This was supported by a fundal appearance 6 weeks later showing no evidence of previous choroidal ischaemia. • It seems that the clinical appearance of a white posterior pole may not always signify ophthalmic artery occlusion.

  20. Comment • The origin of the infection was believed to be a pustular lesion on the inner aspect of the upper lid which grew Staphylococcus aureus. • This is a known cause of orbital cellulitis, but its association with arterial occlusion has not been documented.

  21. References • Brown GC, Larry E, Magargal E, Sergott R. Acute obstruction of the retinal and choroidal circulations. Ophthalmology 1986; 93: 1373-1382.2 • Jarrett WH, Gutman FA. Ocular complications of infection in the Paranasal Sinuses. Arch Ophthalmol 1969; 81: 683-688.3 • Luo QL, Orcutt JC, Seifter LS. Orbital mucormycosis with retinal and ciliary artery occlusions. Br J Ophthalmol 1989; 73: 680-683.4 • Alvi NP, Mafee M, Edward DP. Ophthalmic artery occlusion following orbital inflammation: a clinical and histopathological study. Can J Ophthalmol 1998; 33: 174-179.5 • Henkind P. Symposium: retinal vascular disease. Introduction and phenomenology. Trans Am Acad Ophthalmol Otolaryngol 1977; 83: OP367-OP372.6 • Brown GC, Magargal LE. Sudden occlusion of the retinal and posterior choroidal circulations in a youth. Am J Ophthalmol 1979; 88: 690-693.

  22. End Questions?

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