EMERGENCY CALL ON A FRIDAY AFTERNOON…

DR. HAYAT KHAN

DR. DAN DEANGELIS

PRESENTATION4 year healthy girl

sustained trauma left infra-nasal periorbital area

by running into a tree while tobogganing.

1cm X 1 cm laceration of skin.

Referred to HSC Emergency within 24 hours of injury.

CT Scan Brain and Orbit ordered by Emergency Team at HSC

Referred to eye clinic…

PRESENTATION (CONTD.)Seen by Oculoplastics services at HSC.

H/O:

• Increasing swelling of eye lids since injury(LE).• Redness of the periorbital area(LE).• Painful eye movements left side (LE).• Diplopia since injury.

Child irritable, uncooperative with examination.

Eyelid chemosis & erythema (Lower> Upper) LE

Proptosis associated with Motility restricted.

Visual acuity was difficult to evaluate.

Pupils were equal, round, and briskly reactive to light both eyes.

CT SCANS : AXIAL VIEW

CT SCANS : AXIAL VIEW

CT SCAN CORONAL SECTION

CT SCAN CORONAL SECTION

SAGITTAL VIEW

“If wood has a sharp end and is elongated it can penetrate deep into the orbit and the intracranial cavity through a small entry wound” (Greany, 1994; Mutlukan et al., 1991)

SURGICAL MANAGEMENT – 3RD MARCH 2010

• Examination under Anaesthesia – Nasolacrimal system carefully examined.

• IOP in LE – 32 mmHg … Lateral Canthotomy?

• Wound was cleaned and Specimen collected from the surface.

• Wooden Foreign Body 30 mm removed.

• Retrobulbar irrigation done with Bacitracin mixed with BSS.

• Retrobulbar abscess was drained and drainage tube was left in to be removed in 2 days.

• Suturing done to close the wound and 5-0 silk was used to anchor the drainage tube.

• IOP 18 mmHg in LE at the end of procedure.

• I.V. Antibiotics started – Vancomycin, Ceftriaxone and Metronidazole after discussion with ID.

FOLLOW UPI.V. Antibiotics continued for 1 week and then changed to Oral Ciprofloxin at the time of discharge and given for 1 week.

Unremarkable eye exam except -2 adduction LE on 1st postop day one which improved in 7 days. Vision was recorded 4/6 in each eye.

Drainage tube was dry the next day and was removed on the 2nd postoperative day. Steri-strip was used to close the wound.

Discharged at 1 week with Tobramycin Ointment to be applied locally.

At 1 month Follow – good healing

8 DAYS POSTOPERATIVE PHOTOS

ONE MONTH POSTOPERATIVE PHOTOS

BACTERIOLOGY REPORTSDeep Orbital Aerobic & Anaerobic Swab Left Eye:

• Gram Staining: Many Neutrophils & No Organism

• Results: • Pantoea Agglomerans(Scanty Growth)

• Sensitive to Gentamicin, Piperacillin, Trimethoprim- Sulpha, Tobramycin.

• Resistant to Ampicillin& Cephazolin• Clostridium perfringens (Scanty Growth)• Clostridium Tertium (Scanty Growth)• Klebsiella Ozaenae (Scanty Growth)

• Sensitive to Gentamicin, Piperacillin, Trimethoprim- Sulpha, Tobramycin.

• Resistant to Ampicillin.

MICROBIOLOGY LITERATURE ON ORGANIC FOREIGN BODIES

Case of penetrating orbitocranial injury caused by Wood.

Pus from the brain abscess grew Bacteroides asaccharolyticus and small numbers of anaerobes.

Fusobacterium sp. and Leptotrichia buccalis known to be found.• British Journal of Ophthalmology, 1991,75, 374-376

Expect rare organisms like Veillonella species to grow from organic foreign bodies like small gram-negative anaerobic diplococcus of which little is known was discovered.

• Orbit - 1987, Vol. 6, No. I, pp. 3-15

Staphylococcusaureus &Citrobucter diversus found- sensitive to gentamicin and co-trimoxazole

• Orbit - 1989, Vol. 8, No, 2, pp. 139-142

RADIOLOGICAL ASPECTPlain film radiography is not useful in detecting intraorbital wooden foreign bodies.

Standardized ophthalmic ultrasonography (combine of standardized A-scan and B-scan) has been suggested to be used as an alternative.

Limitations:

• May not be able to evaluate the complete orbit

• Cannot detect intraorbital wood surrounded by air.

Orbit, 27:131–133, 2008.Intraorbital Organic Foreign Body – A Diagnostic Challenge. BritishJournal ofOphthalmology, 1991,75, 374-376 Case of penetrating orbitocranial injury caused

by Wood. Erkan Mutlukan, BrianW Fleck, James F Cullen, Ian R Whittle

CT SCAN ROLEWith the use of CT, several authors were able to detect intraorbital wood.

CT also allowed detection of associated problems such as fractures and abscesses. Wide window widths (up to 1000 HU) were proposed to optimize visibility of intraorbital wood.

Intraorbital wooden foreign body mimics air on standard CT window setting and MR.

Ophthalm Plast Reconstr Surg 1990;6:108–114

Am J Ophthalmol 1988;105:612–617

Radiology 1992;185:507–508.

AJNR Am J Neuroradiol 1993;14:892–895

INTRAORBITAL WOOD FOREIGN BODIES ON CT: USE OF WIDE BONE WINDOW SETTINGS TO DISTINGUISH WOOD FROM AIR

The wide-bone window settings usually reveal the reticulated matrix of wood, which distinguishes wood from simple gas collections.

If wood volume averages as fat density, it is difficult to identify in the orbit on CT.

However, with strong clinical suspicion of wooden foreign bodies and metallic foreign bodies excluded by CT, MR imaging is indicated because of its superiority to CT in detecting dry wooden foreign bodies.

Ophthalm Plast Reconstr Surg 1990;6:108–114

Am J Ophthalmol 1988;105:612–617.

Surv Ophthalmol 1992;36:341–344.

Ophthalmology 1990; 97:608-11

The radiologist reported an “oval gas shadow” between the right medial rectus and the lateral wall of the ethmoid sinus suggestive of a possible collection of pus.

Intraorbital Organic Foreign Body – A Diagnostic Challenge. Orbit, 27:131–133, 2008.

Small objects and those composed of wood or plastic difficult to be detected by imaging.

Orbit – 1998, Vol. 17, No. 4,pp. 247-269Weisman RA, Savino PJ, Schut L, Schatz NJ. Computed tomography in penetrating wounds of the orbit with retained foreign bodies.

Retrospective, non-comparative case series.

Nineteen patients (15 males, 4 females) with penetrating orbital injuries due to organic foreign bodies.

Time of presentation: few hours to 9 months.

Most common injury site superior orbit in 11 (57.9%) patients leading to:

• abnormal extraocular motility (84.2%)• proptosis (68.4%)• upper lid ptosis (47.4%)

Associated pathologies also included:

• acute cellulitis in 11• orbitocutaneous fistula in 5• osteomyelitis in 2 patients.

Preoperative CT and MRI identified the foreign bodies in 42% and 57% of the patients, respectively.

The vision improved shortly after treatment

The long-term complications - extraocular muscle and eyelid motility problems and periorbital scarring.

Penetrating Orbital Injury with Organic Foreign Bodies. Ophthalmology 1999;106:523–532

TAKE HOME MESSAGEEarly clinical signs suggesting a foreign body in the orbit:

• may be displacement of the globe• persisting inflammation• limitation of ocular movement with diplopia.

(Macrae, 1979)

Wood has a density similar to air and fat and can be difficult to distinguish from soft tissue in both a plain X-ray film and a computed tomogram.

(Green et al., 1990; Macrae, 1979;Mutlukan et al., 1991; Specht et al., 1992)

Magnetic resonance imaging is a better method of investigation in cases of a suspected organic intraorbital foreign body.

(Green et al., 1990; Specht et al., 1992)

THANK YOU

BACTERIOLOGY REPORTS

External Aerobic Left Eye Swab:

• Gram Staining: Many Neutrophils & No Organism

• Results: • Staph. aureus (Scanty Growth) – Sensitive to Oxacillin/

cefazolin / cefuroxime, clindamycin, Erythromycin

• Gm. –ve Bacilli (Scanty Growth)

• Clostridium species but not perfringens (Scanty Growth)

KLEBSIELLA OZAENAE A member of the family Enterobacteriaceae

Causes:

• Bacterial endophthalmitis - relatively uncommon.• Rhinoscleroma, a chronic granulomatous infection• Ozena or primary atrophic rhinitis.• Community-acquired pneumonia -◦◦An increased tendency exists toward

abscess formation, cavitation, empyema, and pleural adhesions.• Urinary tract infection• Nosocomial infection• Colonization

Has a role as an invasive pathogen, especially in immunosuppressed hosts

Case reported of a cerebral abscess caused by K. ozaenae.

J Clin Microbiol. 1987 August; 25(8): 1553–1554.

PANTOEA AGGLOMERANSGram-negative bacterium that belongs to the family Enterobacteriaceae.

Formerly called Enterobacter agglomerans

Known to be an opportunistic pathogen in the immunocompromised.

Commonly isolated from plant surfaces, seeds, fruit (ex. - mandarin oranges), and animal or human feces.

It is difficult to differentiate easily from other members of this family, such as, Enterobacter, Klebsiella, and Serratia species.

CLOSTRIDIUM PERFRINGENSClostridium perfringens (Welchii), a gram-positive anaerobic bacillus, may cause gas gangrene following penetrating wounds.

Reported cases of C. perfringens endophthalmitis to more than sixty nine.

The Presentation:

• rapid development of a fulminating panophthalmitis• severe pain• early rise of ocular tension• the appearance of blood or of a thin coffee-colored discharge• the eventual formation of gas bubbles in the anterior chamber• the rapid development of total amaurosis

The patient may be managed successfully by early therapeutic vitrectomy and intravitreal and systemic antibiotic therapy.

Documenta Ophthalmologica 87: 177-182, 1994.

Bacteriological studies of gas gangrene and related infections

Indian Journal of Medical Microbiology. 2003 | Volume : 21 | Issue : 3 | Page : 202-204

Penetrating Orbital Injury with Organic Foreign Bodies. Ophthalmology 1999;106:523–532

Ophthalmology 1999;106:523–532

MICROBIOLOGY

Microbiologic studies during surgery were performed on 13 patients:

• Staphylococcus aureus - 5

• Escherichia coli - 2

• Clostridium subterminale 1

• Haemophilus influenzae 1

• Cultures failed to reveal any causative organism 4

• No fungal infection was detected in this series.