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Acute Proptosis
Mark Soontornvachrin, MDRaghu Mudumbai, MD
Ophthalmology Grand RoundsAugust 9, 2007
History
CC: Right eye swelling HPI: 19 y/o F with acutely progressive swelling and
decreased vision OD x 4 days Poor historian Since swimming 5 days PTA, increasing facial pain,
and RE swelling “Incoherent” per grandfather 1 day PTA Noted by family to hit herself in the RE several times
while asleep 1 day PTA Taken to OSH morning of admission and seen by
outside ophthalmology consult Started on treatment for high IOP OD (90s by Tono-
Pen): Diamox IV, Cosopt, Alphagan Transferred to HMC for definitive care
History
POH: No surgery/trauma PMH: ADHD, developmental delay Meds: Zyprexa, Klonipin All: NKDA SH: Denies T/E/D; from Arlington, WA FH: No ocular disease ROS: Subjective fever, HA, malaise
Exam
Vitals: T 101.2 (at OSH); other VS stable External: Prominent R proptosis with
RUL/RLL edema, RUL ptosis
OD OS VA NLP 20/30 P 3 → 2 3 → 2 +APD OD TP (5%) 28 12
EOM Frozen Full
Exam
SLE LLL: See previous → WNL S/C: Hemorrhagic chemosis → WNL K: Clear OU AC: D&Q OU I: WNL OU L: WNL OU
NDFE No disc swelling/pallor OU
Exam
Questions?
Differential Diagnosis
Differential Diagnosis
Orbital cellulitis Orbital subperiosteal abscess Orbital apex syndrome Cavernous sinus thrombosis
Idiopathic orbital inflammation Orbital mass/tumor Thyroid-associated orbitopathy
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Summary
19 y/o F with acute onset unilateral proptosis R NLP, APD, frozen globe R pansinusitis R orbital cellulitis R medial orbital subperiosteal abscess R cavernous sinus thrombosis
Differential Diagnosis
Orbital cellulitis Orbital subperiosteal abscess Orbital apex syndrome Cavernous sinus thrombosis
Idiopathic orbital inflammation Orbital mass/tumor Thyroid-associated orbitopathy
Cavernous Sinus: Anatomy
Cavernous Sinus: Anatomy
Cavernous Sinus: Anatomy
Cavernous Sinus: Anatomy
Cavernous Sinus: Anatomy
Cavernous Sinus: Anatomy
Cavernous Sinus: Anatomy
Cavernous Sinus: Anatomy
Cavernous Sinus: Anatomy
A: ICA B: CN III C: CN IV D: CN VI E: CN V1
F: CN V2
Cavernous Sinus: Tributaries
Cavernous Sinus: Drainage
Cavernous Sinus: Neuroimaging
Cavernous Sinus Thrombosis (CST)
Thrombophlebitic process affecting the cavernous sinus
Most commonly infectious etiology Occurs as sequelae of local infection (often
concurrently) Orbital cellulitis Subperiosteal abscess Orbital abscess Sinusitis
CST: Pathogenesis
Cavernous sinuses lack valves; allows bi-directional spread of infection
Local spread from infectious source (ie. infected sinus) via draining veins as contiguous phlebitis
Septic emboli from distant source Bacterial growth induces thrombosis Thrombus acts as good growth medium for
more bacterial growth
CST: Sources of Infection
Paranasal sinusitis Ethmoid Sphenoid
Nasal furunculosis Oral/dental infections Middle ear infections
Organisms Staphylococcus aureus (70%) Streptococcus sp. (20%) Gram negatives (5%) Rarely fungal (immunocompromised)
CST: Epidemiology
Typically young adults Uncommon, no incidence data Fatal prior to antibiotic era (pre-1940s) Mortality estimate: 14-79% Morbidity estimate: 50%
Cranial neuropathies Visual loss
CST: Clinical Presentation
Time from initial infection to presentation usually between 1-21 days (average 5-6 days)
Systemic features (sepsis) Headache Fever Tachycardia Hypotension Mental status changes
CST: Ocular Findings
Classically unilateral, then bilateral within days Venous congestion
Chemosis Proptosis Retinal vein dilatation
External ophthalmoplegia Restriction from orbital venous congestion Cranial nerve palsies (CN III, VI, IV)
Ophthalmic anesthesia / maxillary anesthesia Horner’s syndrome Visual loss (rare in isolated CST)
Occlusion of ICA, ophthalmic artery, CRA Ischemic optic neuropathy
CST: Complications
Intracranial infection Meningitis Encephalitis Abscess
Pituitary insufficiency Hemorrhagic infarction Death
CST: Work-Up
CBC Blood cultures Lumbar puncture Neuroimaging (CT, MRI)
Expansion of cavernous sinuses Convex bowing of lateral wall Abnormal filling defects Dilation of superior ophthalmic vein Dural enhancement of cavernous sinus border
CST: Neuroimaging
CST: Treatment
Empiric high dose IV antibiotics Third generation cephalosporin Anti-staphylococcal penicillin Metronidazole
Continued treatment with IV abx for at least two weeks after apparent clinical resolution
Surgical drainage of primary infection sites Steroids controversial (except if pituitary
insufficiency)
CST: Treatment
Anticoagulation No consensus for use despite theoretical
rationale Risks include systemic and intracranial
bleeding 2 cases of intracranial hemorrhage and 2 cases
of systemic hemorrhage reported in literature No prospective randomized trials due to rarity
of CST and risk of hemorrhage
CST: Anticoagulation
Southwick (1986): Retrospective review of 86 case reports of infectious CST from 1940-1984 Heparinized patients (n=28)
Death: 4 (14%) Full recovery: 10 (36%) Recovery with sequelae: 14 (50%)
Non-heparinized patients (n=58) Death 23: (40%) Full recovery 15: (26%) Recovery with sequelae: 20 (34%)
Differences were statistically significant Probably confounded by reporting bias
Case Follow-Up
Ceftriaxone, vancomycin, metronidazole started LP and blood cultures did not grow any organisms Otolaryngology drained sinuses endoscopically IOP remained elevated in mid-30s throughout
hospitalization; VA remained NLP Otolaryngology revised previous sinus surgery and
decompressed orbit (medial wall, floor) Surgical cultures grew MSSA; abx changed to
nafcillin IV and metronidazole Patient discharged with home IV abx for 6 weeks
Case Follow-Up
Ophthalmology follow-up 1 week after d/c Comfortable right eye NLP Pupil 6 mm, non-reactive, +APD OD TA 16 (on Diamox, Alphagan, Cosopt) Markedly improved proptosis Severely motility restriction in all directions Complete RUL ptosis Decreased corneal sensation Normal anterior and posterior segment exam
Summary
Suspect cavernous sinus thrombosis in the setting of acute unilateral proptosis
Frequent etiologies include sinus and facial infections
Concurrent orbital cellulitis and/or orbital apex syndrome may occur
IV antibiotics clearly reduce mortality and need to be started immediately
Anticoagulation is controversial, but can consider in cases of clot expansion
References Bhatia K, Jones NS. Septic cavernous sinus thrombosis secondary to
sinusitis: Are anticoagulants indicated? A review of the literature. J laryngol Otol. 2002;16:667-676
Bilyk JR and Jakobiec FA. Chapter 32: Embryology and anatomy of the orbit and lacrimal system in Duane’s Ophthalmology (2007)
Cannon ML et al. Cavernous sinus thrombosis complicating sinusitis. Pediatr Crit Care Med 2004;5(1):86-88
Enbright JR et al. Septic thrombosis of the cavernous sinuses. Arch Intern Med 2001;161:2671-2676
Pavlovich P et al. Septic thrombosis of the cavernous sinus: Two different mechanisms. Orbit 2006;25:39-43
Southwick FS et al. Septic thrombosis of the venous dural sinuses. Medicine. 1986;65:82-106
Watkins LM et al. Bilateral cavernous sinus thromboses and intraorbital abscesses secondary to Streptococcus milleri. Ophthalmology 2003;110:569-574
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