Download Severe Orbital Inflammation as a Complication of Primary

Authors:
K Michael, D Lyall, D Anijeet, S Mantry, K Ramaesh.
Tennents Institute of Ophthalmology
NHS Greater Glasgow and Clyde
Glasgow
United Kingdom
Financial Disclosures
None declared for all authors
Introduction
Severe orbital inflammation from an infective cause is
a rare ophthalmological emergency. It is often
caused by progression of sinusitis or skin trauma in the
form of orbital cellulitis1.
The development of severe orbital inflammation from
an infective cornea is rare. More commonly they
progress to cause perforation and endophthalmitis.
CASE SERIES
Case 1
85 year old man presented with
2 days history of eye pain,
reduced vision, pressure
sensation and photophobia.
He presented 2 days prior with
a 16mm2 epithelial defect, and
was treated with lubricants.
Examination showed vision of
light perception, near total
corneal epithelial defect,
conjunctival chemosis,
hypopyon with corneal
thinning.
Day 1
Day 7
He was commenced on
intensive topical
antibiotics, but
developed signs of
scleritis after 7 days.
Oral corticosteroid was commenced (60 mg)
7 days later, he developed signs of orbital cellulitis,
confirmed on MRI imaging.
MRI Report:
“Diffuse inflammatory/infective change affecting left globe
extending along intra-orbital optic nerve, with small collection
related to sclera.”
: Affected
globe
: Affected optic
nerve
: Diffuse
inflammatory
change involving
optic nerve sheath
: Choroidal effusion
Following discussion with the microbiologist, he started
a course of high dose intravenous antibiotics
He showed signs of recovery after 48 hours, and was
discharged home after completion of intravenous
antibiotics course
5 months later, during his final clinic visit his vision
remained poor at hand movements only from diffuse
corneal scarring and pan ocular disruption
6 months later: thinned
ectatic sclera with
corneal scarring
Case 2
65 year old lady presented with 2 days history of red
painful eye with decreased vision.
Examination showed 33mm2 corneal epithelial defect
with white infiltrate, hypopyon with conjunctival
injection with chemosis.
Her previous ocular history includes recurrent herpetic
kerato-uveitis with geographical ulceration.
Eye image
Day 1
5 days later, despite intensive topical treatment, she
began to develop scleritis with signs of orbital cellulitis,
confirmed on MRI imaging.
She was commenced immediately on high dose
intravenous antibiotics and topical corticosteroid.
MRI report:
Left sided proptosis. Diffuse thickening with
enhancement of the sclera of the left globe and minor
inflammation of distal optic nerve sheath…
…minor thickening of left distal lateral rectus and
superior palpebra superioris muscles.
MRI head with contrast:
Inflammatory tissue extending
into post septal intra-conal space
involving optic nerve sheath
Day 5
Day 8
Her condition showed signs of recovery after 48 hours,
and systemic corticosteroids were started after a
week.
She continued to improve although her vision
remained poor at light perception only, from diffuse
corneal scarring with pan ocular disruption.
Clinic Visit
7 weeks post presentation
6 months post presentation :
ectatatic thinned sclera with
corneal scarring
Case 3
53 year old contact lens wearer
returned from holidays with a
painful, red left eye with poor
vision.
Examination showed 34mm2
corneal epithelial defect with
hypopyon, conjunctival
injection and chemosis.
He was commenced on
intensive topical antibitiotics
Day 1
4 days later despite intensive treatment, he
complained of worsening pain around the orbit and
had mild restriction in ocular movements.
CT orbit showed signs of preseptal cellulitis.
He was commenced on high dose of intravenous
antibiotics.
Day 4
CT Scan report:
Left preseptal
cellulitis (
)
2 days later he was also received intravenous
methylprednisolone.
48 hours later he showed signs of recovery, and was
discharged home with intensive topical antibiotics.
He was discharged home and and reviewed regularly
as an outpatient.
Summary
Table 1: Summary of clinical presentations
Age/ge
nder
Onset
(days)
Epithelial
defect area
(mm2)
Hypopyon
Chemosis
Scleritis
Final
Visual
Acuity
(Snellen)
85/m
2
16
yes
yes
yes
HM
65/f
2
33
yes
yes
yes
HM
52/m
5
35
yes
yes
yes
6/36
Table 2: Summary of clinical management
Topical
Abx
Topical
steroids
Systemic
Abx
Systemic
steroids
Inpatient
duration
Systemic
history
Ocular
history
85/m
yes
yes
yes
yes
29
nil
Idiopathic
corneal
oedema
65/f
yes
no
yes
yes
15
nil
Recurrent
herpetic
keratouveitis
52/m
yes
yes
yes
yes
10
nil
Contact lens
wearer
Discussion
Severe orbital inflammation is a rare consequence of
corneal ulcers1. More common consequence of
corneal ulcers include corneal scarring and
perforations.
Endophthalmitis may occur in immunocompromised
individuals. The current literature has only described
one case where Pseudomonas aeruginosa associated
orbital cellulitis and corneal ulcer co-existed, in a 3
month old child in 19792.
The aim of our case series is to highlight our concern
at disease progression despite the recommended
treatment.
2 patients suffered potentially fatal complication,
while 1 patient showed relatively mild symptoms.
All 3 patients improved with high dose intravenous
antibiotics and steroids.
However, all 3 patients has poor visual prognosis
following recovery.
Pseudomonas aeruginosa are known to be
opportunistic pathogen, with high potential for
adaptability in compromised ocular environment.
This quality is further enhanced by its ability to
produce toxins and proteases, as well as the unique
type 3 secreting mechanism as a mode of
transfection3
Breakdown of its endotoxins are also believed to be
pro-inflammatory, may cause severe additional local
tissue immune response4
The net combination of simultaneously occurring
reactions may be responsible for the intense
inflammatory response.
Conclusion
• Clinicians should be mindful of the potential
worsening progression of disease despite receiving
treatment of choice
• These cases are likely to illustrate the following:
o New drug resistance developed by Pseudomonas aeruginosa
o Secondary inflammatory mechanisms by released endotoxins
• The role and interactions of systemic steroids with
active infective process is unclear
• Although rare, we recommend close monitoring of
large Pseudomonas aeruginosa associated corneal
ulcers due to its potential for worsening and intense
inflammation
References
1. Westfall CT. Infectious processes of the orbit. In: Albert DM, editor.
Principles and Practice of Ophthalmology, 2nd edition. Kidlington, UK:
WB Saunders, 2000:3121-3130
2. Weiss IS. Pseudomonas Orbital Cellulitis. American Journal of
Ophthalmology. 1979 Mar;87(3):368-70
3. Kipnis E, Sawa T, Weiner-Kronish J. Targeting mechanisms of
Pseudomoans aeruginosa pathogenesis. Médecine et maladies
infectieuses 2006;36: 78-91
4. Sato H, Frank DW. ExoU is a potent intracellular phospholipase.
Molecular Microbiology. 2004;53(3):1275-1296