An 80-year-old male with diabetes mellitus, mild diabetic retinopathy, and mild dementia underwent reported uncomplicated, bilateral FESS for chronic sinusitis with polyposis at an outside hospital. He was provided an outpatient prescription for amoxicillin-clavulanic acid upon outpatient surgical discharge. Initial pathology specimen within the immediate postoperative period from the outside hospital was reported as non-invasive Aspergillus. He was seen by his original surgeon at the outside facility on postoperative day 3 without visual complaints or unexpected facial pain. On postoperative day 4, the patient reported sudden right-sided vision loss and presented to the walk-in ophthalmology clinic at the primary author’s tertiary care facility. An ophthalmology exam found no perception of light on the right and an abducens nerve palsy. Pupils were equal and reactive to light bilaterally with no pallor of the optic disc and normal ocular pressures. He was sent immediately to the emergency department for imaging, whereupon the otolaryngology team evaluated the patient. Intranasal exam by otolaryngology was only notable for moderate edema of the nasal mucosa without necrosis or pallor. There was no decreased sensation of the palate or midface. Computed tomography was performed and notable for violation of the lamina papyracea (Figure ). Preoperative imaging from the outside facility was not available for comparison. Magnetic resonance imaging suggested acute ischemic findings of the right optic nerve with diffusion restriction at the proximal optic nerve without evidence of thrombosis or hemorrhage. Subsequent imaging after admission noted an abnormal T2 signal without canalicular segment enhancement. There was, however, some adjacent enhancement extending to involve the optic and nerve sheaths in the orbital apex and superior orbital fissure. The enhancement of the right-sided nerve sheaths was thought to be contributing both to the vision loss and the abducens nerve palsy that was defining the OAS. In addition to those mentioned, the neurosurgery, neurology, and internal medicine teams evaluated the patient. It should be noted that repeated images were obtained at several time points due to poor images from motion artifact that did delay care. The clinical and radiologic findings were determined by the treating teams to be most suggestive of the surgical trauma from the FESS at the outside facility and not of an infectious origin. A non-surgical approach was initially pursued. The patient was provided broad-spectrum antibiotics and high-dose steroids to decrease inflammation with close neurologic monitoring. Re-evaluation by otolaryngology on flexible nasal endoscopy did not show any change in findings of the nasal mucosa.\nOn postoperative day 9 from the original FESS, the patient developed sudden vision loss of the left eye. An ophthalmology exam noted no light perception bilaterally, worsening ophthalmoplegia on the right with decreased supraduction, adduction, and infraduction in addition to the complete abducens palsy. These findings suggested now the involvement of the oculomotor and trochlear nerves. The posterior ocular exam now showed mild optic nerve pallor on the right with good color on the left and no evidence of edema. Repeat computed tomography and magnetic resonance imaging noted no new bony destruction; however, there was persistent inflammation of the right optic canal. An emergent multidisciplinary team meeting was held between all consulting specialties and infectious disease was also consulted as the initial diagnosis of traumatic neuropathy was questioned. The patient then underwent emergent FESS with otolaryngology and neurosurgery with decompression of both optic nerves, sphenoidotomy, septectomy, and mucosal stripping (Figure ). The lamina papyracea and bone adjacent to the root of the right orbital apex were dehiscent as had been suggested on imaging (Figure ). Additionally, there was a large amount of absorbable packing in the posterior ethmoid cavity on the right.\nA final culture from the initial FESS at the outside hospital was re-evaluated by the infectious disease team, which revised the diagnosis of Aspergillus to that of S. apiospermum. This pathologic diagnosis was made on postoperative day 10 (postoperative day 1 from emergent FESS). The patient was started on high-dose voriconazole and amphotericin B. The patient continued on maximum medical therapy and continued to worsen clinically and radiologically regarding the infection. Unfortunately, after prolonged hospitalization, he suffered a myocardial infarction and subsequent severe gastrointestinal bleeding. He passed away on postoperative day 47 from the initial FESS after being transferred to inpatient hospice services.
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.