Multifocal Choroiditis

Grand RoundsGrand Rounds

Neha PatelNeha Patel

University of ChicagoUniversity of Chicago

Case presentationCase presentation

A 72-year-old African-American A 72-year-old African-American woman presented with decreased woman presented with decreased vision and progressive swelling in vision and progressive swelling in the left periorbital region the left periorbital region

She had a history of tearing for She had a history of tearing for three months, and discomfort for three months, and discomfort for one month one month


The patient had been treated at an The patient had been treated at an outside hospital with intravenous outside hospital with intravenous antibiotic therapy for three days. antibiotic therapy for three days. However, due to lack of clinical However, due to lack of clinical improvement, she was transferred to improvement, she was transferred to the University of Chicagothe University of Chicago

She had been treated with She had been treated with Vancomycin, Clindamycin, and Vancomycin, Clindamycin, and UnasynUnasyn


PMH: Hypertension PMH: Hypertension

Meds: Norvasc, colace, morphineMeds: Norvasc, colace, morphine

Past ocular history: no trauma, no Past ocular history: no trauma, no surgerysurgery

Clinical ExamClinical Exam

RightRight LeftLeft

VisionVision 20/80 20/80 (near)(near)

CFCF

PupilsPupils normalnormal + APD+ APD

IOPIOP 2323 4545

MotilityMotility Full Full Frozen Frozen globeglobe

Color visionColor vision 11/1111/11 01/1101/11

Differential DiagnosisDifferential Diagnosis

Orbital CellulitisOrbital Cellulitis DacryocystitisDacryocystitis Orbital PseudotumorOrbital Pseudotumor Thyroid OphthalmopathyThyroid Ophthalmopathy

DacryocystitisDacryocystitis

Acute dacryocystitis usually Acute dacryocystitis usually presents as a preseptal infection presents as a preseptal infection

Erythema and swelling below the Erythema and swelling below the medial canthal tendonmedial canthal tendon

Pain is variablePain is variable Acute dacryocystitis rarely leads to Acute dacryocystitis rarely leads to

orbital cellulitis orbital cellulitis – Decreased vision, APD, restricted Decreased vision, APD, restricted

motilitymotilityOrbit, Eyelids, and Lacrimal System. AAO 2003-2004

Chronic DacryocystitisChronic Dacryocystitis

Chronic tear stasis and retentionChronic tear stasis and retention Painless purulent reflux from the Painless purulent reflux from the

lacrimal sac lacrimal sac Organisms: Staphylococcus Organisms: Staphylococcus

species, Corynebacterium species, Corynebacterium diphtheroides, actinomyces diphtheroides, actinomyces

OrganismOrganism

Cause of dacryocystitis is Cause of dacryocystitis is changingchanging

Staph., Strep, few gram negative Staph., Strep, few gram negative organisms in the pastorganisms in the past

Newer data shows an increased Newer data shows an increased prevalence of Gram negative prevalence of Gram negative organismsorganisms


Prospective study in 39 patients Prospective study in 39 patients who presented in clinic with acute who presented in clinic with acute or chronic purulent dacryocystitisor chronic purulent dacryocystitis

Patients were all antibiotic free for Patients were all antibiotic free for one week prior to culturesone week prior to cultures

16 (39%) isolates were Gram 16 (39%) isolates were Gram positivepositive

25 (61%) isoloates were Gram 25 (61%) isoloates were Gram negativenegative

Briscoe D. et al. Changing bacterial isolates and antibiotic sensitivities of purulent dacryocystitis. Orbit. 2005 Jun;24(2):95-8.


The most common isolates were The most common isolates were Pseudomonas (22%), Staphylococcus Pseudomonas (22%), Staphylococcus aureus (13%), Enterobacter (10%), aureus (13%), Enterobacter (10%), Citrobacter (10%), Streptococcus Citrobacter (10%), Streptococcus pneumoniae, Escherichia coli, and pneumoniae, Escherichia coli, and Enterococcus (7%)Enterococcus (7%)

A higher incidence of Gram-negative A higher incidence of Gram-negative organisms, particularly Pseudomonas, organisms, particularly Pseudomonas, with resistance to commonly used with resistance to commonly used antibiotics was found. antibiotics was found.

Briscoe D. et al. Changing bacterial isolates and antibiotic sensitivities of purulent dacryocystitis. Orbit. 2005 Jun;24(2):95-8.


Most patients with dacryocystitis Most patients with dacryocystitis develop preseptal cellulitis and develop preseptal cellulitis and not orbital extension not orbital extension

Prevention of spread to the orbit Prevention of spread to the orbit is attributed to the orbital septum is attributed to the orbital septum by its insertion on the posterior by its insertion on the posterior lacrimal crestlacrimal crest

Mauriello JA, Wasserman BA. Acute dacryocystitis: an unusual cause of life-threatening orbital intraconal abscess with frozen globe. Ophthal Plast Reconstr Surg. 1996;12:294


Other barriers exist posteriorly, including Other barriers exist posteriorly, including the lacrimal fascia, the posterior limb of the lacrimal fascia, the posterior limb of the medial canthal ligament, and deep the medial canthal ligament, and deep heads of the pretarsal and preseptal heads of the pretarsal and preseptal orbicularis muscles orbicularis muscles

Once the posterior barriers of the lacrimal Once the posterior barriers of the lacrimal sac have been breached, access to the sac have been breached, access to the intraconal space is essentially unimpeded intraconal space is essentially unimpeded and rapid vision loss can occurand rapid vision loss can occur

Younger patients (<3 years) Younger patients (<3 years) tended to have single isolates, tended to have single isolates, and older patients tended to have and older patients tended to have polymicrobial infections polymicrobial infections

These findings parallel those seen These findings parallel those seen in orbital abscesses secondary to in orbital abscesses secondary to sinus disease sinus disease

Harris GJ. Subperiosteal abscess of the orbit: age as a factor in the bacteriology and response to treatment. Ophthalmology. 1994;101:585-595

Prior dacryocystitis is a possible Prior dacryocystitis is a possible risk factor for orbital extension. risk factor for orbital extension.

Distension of the lacrimal sac Distension of the lacrimal sac during episodes of dacryocystitis during episodes of dacryocystitis can stretch the lacrimal sac walls can stretch the lacrimal sac walls and its posterior barriersand its posterior barriers

These barriers weaken from These barriers weaken from distension and cause breaches, distension and cause breaches, increasing the likelihood of increasing the likelihood of posterior spreadposterior spread

Kikkawa DO et al. Orbital cellulitis and abscess secondary to dacryocystitis.Arch Ophthalmol. 2002 Aug;120(8):1096-9


Although intravenous antibiotics Although intravenous antibiotics should be initiated immediately, should be initiated immediately, surgical drainage is the definitive surgical drainage is the definitive treatment treatment

DacryocystorhinostomDacryocystorhinostomy y Creating a anatomosis between Creating a anatomosis between

the lacrimal sac and nasal cavity the lacrimal sac and nasal cavity through a bony ostiumthrough a bony ostium

ExternalExternal

Health & Medicine

Multifocal Choroiditis