A 54-year-old female patient presented to us with pain,\nswelling of lids of the right eye (RE) associated with intense\nchemosis and congestion of the conjunctiva. She was a\nknown diabetic since 20 years and a hypertensive since\n15 years. She had received posterior subtenon triamcinolone\n20 mg injection with a 20-gauge veinflow canula in her RE\nimmediately following focal laser treatment 3 days back for\ndiabetic macular edema. At presentation her vision in RE was\nhand movement close to face (HMCF) and the same in the\nleft eye (LE). Intraocular pressure could not be measured in\nRE due to massive lid edema. It was recorded as 14 mmHg in\nLE. The RE revealed lid edema with erythema []. The\ntemperature of the overlying skin was raised but there was no\npalpable mass. The conjunctiva was congested and chemosed.\nExtraocular movements were limited in all directions of gaze\nin RE. In LE the movements were full in all directions. On\nforcibly lifting the upper lid of RE there was frank white\ntenacious discharge from the site of subtenon injection along\nwith necrosis of the surrounding conjunctiva and peripheral\ncorneal infiltrate []. Pupillary reaction was normal.\nPosterior segment examination showed proliferative diabetic\nretinopathy (PDR) with clinically significant macular edema\n(CSME) in both eyes.\nMicrobiological investigation of the discharge and infiltrate\nshowed the presence of gram-positive cocci in clusters but no\ngrowth was observed on culture. Her fasting blood sugar was\n284 mg% at presentation. Thereafter she was started on insulin\ninfusion along with intravenous ciprofloxacin 500 mg twice\ndaily, vancomycin 1 g twice a day and metrogyl 80 mg twice\ndaily along with topical moxifloxacin 0.3% six times a day and\natropine thrice a day. She had previously received injection\ncefazolin and ciprofloxacin elsewhere for 1 day. Computed\ntomography (CT) of head was consistent with diagnosis of\norbital abscess [] with no involvement of optic nerve.\nThere was no evidence of intracranial involvement.\nOver the next 3 days there was very little improvement. At\nthis moment oral linazolid 500 mg twice a day was added to the\ndrug regimen suspecting methicillin and vancomycin-resistant\nStaphylococcus aureus. There was remarkable improvement in\nthe ensuing 48 h. Lid edema reduced considerably along with\ndecrease in conjunctival chemosis and congestion. Extraocular\nmovements improved and the discharge was seemingly much\nless than before. The above treatment continued for a period\nof 7 days. At 3 weeks follow-up all parameters were normal\nexcept for adjacent conjunctival and corneal scarring [].\nVisual acuity improved to 20/200. There was no restriction of\nocular movements.
A 48-year-old man with diabetes mellitus who had failed to adhere to his treatment presented to the emergency department with complaints of a right-sided headache and toothache for two weeks, with nausea and vomiting for two days prior to presentation. The patient was managed for septic shock secondary to dental abscesses. Non-contrast brain computed tomography (CT) was performed. The CT scan showed no significant intracranial abnormality other than pansinusitis, without obvious retro-orbital fat streakiness (Figure ). Four days later, tooth number 17 and 18 in the left mandibular region, both of which had abscesses, were extracted. The patient noted progressive painless blurring of the vision in his right eye post-extraction of the abscessed teeth and was referred to the ophthalmology team two days later. At this time, the patient was receiving day five of treatment with intravenous (IV) amoxicillin-clavulanate, (1.2 g three times a day), with the addition of IV metronidazole (400 mg twice a day).\nThe visual acuity (VA) in his right eye was 4/60, with no improvement in the pinhole test. A relative afferent pupillary defect was present, with an associated decrease in the optic nerve function, in addition to ophthalmoplegia and restrictions in the superior and lateral gaze. No proptosis, ptosis or lid swelling was present, and all other anterior segment findings were normal. A fundus examination of the right eye showed only proliferative diabetic retinopathy. The VA in the patient’s left eye was 6/18 and 6/9 in the pinhole test. An examination of the anterior segment was unremarkable. Moderate non-proliferative diabetic retinopathy was detected in the posterior segment. Dental caries were present in the upper molars, with mucopurulent discharge from the right sphenoid sinus region. The clinical diagnosis was OAS, and emergency functional endoscopic sinus surgery and septoplasty were performed by the ear, nose and throat (ENT) team. Intra-operatively, pus (6cc) was drained from the right sphenoid sinus. The pus breached the anterior sphenoid wall, tracked down to the septum polypoidal mucosa over the right maxillary sinus and right anterior and posterior ethmoid sinuses.\nEmpirical treatment with IV ceftriaxone (1 g twice a day) and IV fluconazole (400 mg once a day) was started. Despite the commencement of IV antibiotic and antifungal treatment, the patient’s condition deteriorated, and the VA in this right eye was classified as no perception of light (NPL) and almost total ophthalmoplegia four days post-presentation (Figure ). Treatment with IV methylprednisolone was not started in view of the infective nature of the disease and the possibility of a fungal infection, which could worsen his condition.\nMethicillin-resistant Staphylococcus aureus was isolated from the pus and from a nasal swab. IV vancomycin (1 g twice a day) and IV metronidazole (400 mg twice a day) were added. An urgent non-contrast CT brain scan was repeated and revealed features suggestive of fungal pansinusitis, with the involvement of the right orbital apex and right orbital contents (Figure ). No suspicious intracranial lesion was seen. The patient underwent emergency nasal debridement for the second time and septotomy. A bony dehiscence was noted over the right posterior ethmoid supralaterally, exposing the orbital apex.\nOn day 13 after the first surgical drainage, tissue culture from the septal wall yielded S. apiospermum. IV amphotericin B (35 mg once a day) was commenced. However, the patient’s renal profile deteriorated following the amphotericin B treatment. Thus, the antifungal regime was changed to oral voriconazole (200 mg twice a day), but the patient failed to respond to the treatment. Forty days after the initial presentation, he developed invasive pansinusitis, with disease progression involving the base of the skull (both orbits) and intracranial extension.\nAt this stage, the VA in the patient’s right eye was classified as NPL in all four quadrants, with almost total ophthalmoplegia. The VA in his left eye was 6/12, with full extraocular movement. The neurosurgical team decided against any surgical intervention. Functional endoscopic sinus surgery was performed for the third time, with nasal toileting. Intra-operatively, minimal crusting was observed over the right nasal cavity. The right sphenoid, pterygoid, maxillary sinuses and the frontal sinuses were clear, with no pus. The mucosa was healthy, with minimal bleeding. The left maxillary sinus was also clear.\nIV amphotericin B was restarted, but the patient developed gastrointestinal intolerance. The antifungal treatment was again changed to oral voriconazole (200 mg twice a day). Fifty-seven days after the initial presentation, the VA in the patient’s left eye decreased suddenly to 6/30 (reduced Snellen chart), and his colour vision decreased. A plain and contrast-enhanced CT scan of the brain, orbit and the paranasal sinuses showed invasive pansinusitis, with bilateral orbital apex involvement (Figure ). It also showed an increasing intracranial extension involving the right cavernous sinus anteriorly, the roof of the sphenoid sinus, the floor of the anterior cranial fossa and right medial cranial fossa anteriorly, as well as osteomyelitis changes at the base of the skull. In view of the acute progression of the infection, surgical intervention was considered. However, the area of the lesion was too extensive and was beyond ophthalmology coverage. Following a reassessment by the neurosurgical team, a decision was made to continue medical treatment rather than perform a surgical intervention.\nSIxty-seven days after the initial presentation, the patient’s VA decreased to NPL in both eyes. Although his Glasgow coma scale was full, his general condition worsened, with lethargy, irritability and dizziness, accompanied by nausea and vomiting. The patient decided to discharge himself from the hospital (at own risk discharge) and subsequently failed to attend an appointment in the ophthalmology clinic.