Multifocal Choroiditis


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Mutlifocal Choroiditis

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Multifocal Choroiditis

  1. 1. Grand Rounds Neha Patel University of Chicago
  2. 2. Case presentation <ul><li>A 72-year-old African-American woman presented with decreased vision and progressive swelling in the left periorbital region </li></ul><ul><li>She had a history of tearing for three months, and discomfort for one month </li></ul>
  3. 3. Case presentation <ul><li>The patient had been treated at an outside hospital with intravenous antibiotic therapy for three days. However, due to lack of clinical improvement, she was transferred to the University of Chicago </li></ul><ul><li>She had been treated with Vancomycin, Clindamycin, and Unasyn </li></ul>
  4. 4. Case presentation <ul><li>PMH: Hypertension </li></ul><ul><li>Meds: Norvasc, colace, morphine </li></ul><ul><li>Past ocular history: no trauma, no surgery </li></ul>
  5. 5. Clinical Exam 01/11 11/11 Color vision Frozen globe Full Motility 45 23 IOP + APD normal Pupils CF 20/80 (near) Vision Left Right
  6. 8. Differential Diagnosis <ul><li>Orbital Cellulitis </li></ul><ul><li>Dacryocystitis </li></ul><ul><li>Orbital Pseudotumor </li></ul><ul><li>Thyroid Ophthalmopathy </li></ul>
  7. 9. Dacryocystitis <ul><li>Acute dacryocystitis usually presents as a preseptal infection </li></ul><ul><li>Erythema and swelling below the medial canthal tendon </li></ul><ul><li>Pain is variable </li></ul><ul><li>Acute dacryocystitis rarely leads to orbital cellulitis </li></ul><ul><ul><li>Decreased vision, APD, restricted motility </li></ul></ul>Orbit, Eyelids, and Lacrimal System. AAO 2003-2004
  8. 10. Chronic Dacryocystitis <ul><li>Chronic tear stasis and retention </li></ul><ul><li>Painless purulent reflux from the lacrimal sac </li></ul><ul><li>Organisms: Staphylococcus species, Corynebacterium diphtheroides, actinomyces </li></ul>
  9. 11. Organism <ul><li>Cause of dacryocystitis is changing </li></ul><ul><li>Staph., Strep, few gram negative organisms in the past </li></ul><ul><li>Newer data shows an increased prevalence of Gram negative organisms </li></ul>
  10. 12. Dacryocystitis <ul><li>Prospective study in 39 patients who presented in clinic with acute or chronic purulent dacryocystitis </li></ul><ul><li>Patients were all antibiotic free for one week prior to cultures </li></ul><ul><li>16 (39%) isolates were Gram positive </li></ul><ul><li>25 (61%) isoloates were Gram negative </li></ul>Briscoe D. et al. Changing bacterial isolates and antibiotic sensitivities of purulent dacryocystitis. Orbit. 2005 Jun;24(2):95-8.
  11. 13. Dacryocystitis <ul><li>The most common isolates were Pseudomonas (22%), Staphylococcus aureus (13%), Enterobacter (10%), Citrobacter (10%), Streptococcus pneumoniae, Escherichia coli, and Enterococcus (7%) </li></ul><ul><li>A higher incidence of Gram-negative organisms, particularly Pseudomonas, with resistance to commonly used antibiotics was found. </li></ul>Briscoe D. et al. Changing bacterial isolates and antibiotic sensitivities of purulent dacryocystitis. Orbit. 2005 Jun;24(2):95-8.
  12. 15. Dacryocystitis <ul><li>Most patients with dacryocystitis develop preseptal cellulitis and not orbital extension </li></ul><ul><li>Prevention of spread to the orbit is attributed to the orbital septum by its insertion on the posterior lacrimal crest </li></ul>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
  13. 16. Dacryocystitis <ul><li>Other barriers exist posteriorly, including the lacrimal fascia, the posterior limb of the medial canthal ligament, and deep heads of the pretarsal and preseptal orbicularis muscles </li></ul><ul><li>Once the posterior barriers of the lacrimal sac have been breached, access to the intraconal space is essentially unimpeded and rapid vision loss can occur </li></ul>
  14. 17. <ul><li>Younger patients (<3 years) tended to have single isolates, and older patients tended to have polymicrobial infections </li></ul><ul><li>These findings parallel those seen in orbital abscesses secondary to sinus disease </li></ul>Harris GJ. Subperiosteal abscess of the orbit: age as a factor in the bacteriology and response to treatment. Ophthalmology. 1994;101:585-595
  15. 18. <ul><li>Prior dacryocystitis is a possible risk factor for orbital extension. </li></ul><ul><li>Distension of the lacrimal sac during episodes of dacryocystitis can stretch the lacrimal sac walls and its posterior barriers </li></ul>
  16. 19. <ul><li>These barriers weaken from distension and cause breaches, increasing the likelihood of posterior spread </li></ul>Kikkawa DO et al. Orbital cellulitis and abscess secondary to dacryocystitis. Arch Ophthalmol. 2002 Aug;120(8):1096-9
  17. 20. Dacryocystitis <ul><li>Although intravenous antibiotics should be initiated immediately, surgical drainage is the definitive treatment </li></ul>
  18. 21. Dacryocystorhinostomy <ul><li>Creating a anatomosis between the lacrimal sac and nasal cavity through a bony ostium </li></ul><ul><li>External </li></ul>