Basic ophthalmology for dentists

1. Cavernous sinus thrombosis
Ahmed Osama Hashem
Fellow Royal College ophth
PhD,MD Lecturer,consultant of ophthalmology

2. Cavernous Sinus
• The cavernous sinus is part of the dural venous system.
• Valve less and therefore allows both anterograde and retrograde flow.
• It contains multiple trabeculae that can trap thrombi and bacteria.
• It sits above the sphenoid sinus and contains many important
structures, including the carotid artery and cranial nerves III, IV and
VI, as well the first and second divisions of V.

3. Septic cavernous sinus thrombosis
• A potentially fatal condition. Septic cavernous sinus thrombosis is
rare but is associated with significant morbidity and mortality.
• In the pre-antibiotic era, the condition was fatal in nearly 100 percent
of cases, and mortality still remains high at 20 to 30 percent.
• In addition, significant morbidity can include blindness, cranial
neuropathies and hemiplegia from compromise of the internal carotid
artery.
• There is significant risk of developing meningitis and, due to the
intimate relationship of the cavernous sinus with the pituitary gland,
Addisonian crisis.

7. Dangerous area of the face(Dangerous
triangle)

8. Symptoms and Signs
-Septic thrombosis of the cavernous sinus can occur by :
Direct extension from the sphenoid sinus.
Indirect extension from the ethmoid sinus via the superior ophthalmic
vein, and posterior extension as a complication of orbital cellulitis.
-Other potential routes of infection
include carbuncles in the medial third
of the face and dental infections.

9. Presentation
• Acute and fulminant with bilateral ophthalmoplegia.
• Rarely It can be subacute and more subtle. Headache is the most
common initial symptom, and it usually presents as sharp forehead
and retro-orbital pain along the distribution of V1 and V2 nerves.
• Hypoesthesia or hyperesthesia along V1 and V2 is also possible.
• Owing to the central location of cranial nerve VI in the cavernous
sinus, abduction deficit (Inward deviation) predominates and is also
the last to resolve with treatment.
• Ptosis may be the result of orbital venous congestion, sympathetic
paresis or cranial nerve III palsy.

10. Symptoms

11. Ptosis

12. Ophthalmoplegia,,, Chemosis

13. Bilateral

16. Laboratory
• High WBCs count
• Lumbar puncture.

17. CT orbit

24. Abuction defect (esotropia) Inward deviation..

25. Treatment
- Owing to the rarity of septic cavernous sinus thrombosis, prospective
trials are lacking and there is significant controversy as to optimal
treatment, which always includes :
• High-dose intravenous antibiotics. (Route)
• Antibiotics must be continued for more than three weeks due to poor
penetration into thrombi.(Duration)

26. Treatment
• Causative organisms are commonly gram positive bacteria—such as
streptococcal species, like pneumococcus, or staphylococcal species—
but anaerobes, gram negative organisms and fungi also have been
implicated.
• Combination of a penicillinase-resistant penicillin and a third or fourth
generation cephalosporin is the standard empiric regimen.
• If there is evidence of sinusitis or dental infection, anaerobic
coverage is added.

27. Treatment
• Anticoagulation is a controversial adjunctive therapy. It should only be
initiated after ruling out contraindications, such as intracranial
hemorrhage and cerebral infarction.
• There is significant concern for the increased risk of bleeding
complications. However, retrospective observations suggest that
anticoagulation is beneficial when started early and is recommended
when thrombosis remains unilateral.
• Heparin

28. Treatment
• Steroids also can be considered, as they have been credited with
decreasing the rate of cranial nerve dysfunction.
• They are especially useful in cases of Addisonian crisis.
• However, steroids should not be initiated until proper antibiotic
therapy has been initiated. Finally, surgical drainage of any
intracranial abscesses or involved sinuses can be considered.

29. DD
• Orbital cellulitis
• Orbital Pseudotumour

30. Differential diagnosis ? Is it orbital cellulitis?
• Although septic cavernous sinus thrombosis is rare, its early
presentation can masquerade as the more commonly seen orbital
cellulitis.
• It must always be kept on the differential of infectious causes of
proptosis. Subtle signs such as selective ophthalmoplegia and ocular
misalignment, which are not typically seen in orbital cellulitis, should
not be overlooked.
• Signs suggestive of meningitis should always be noted in a standard
review of symptoms.
• If neuroimaging is performed, evaluating the superior ophthalmic
vein and the cavernous sinus should be routine parts of the review

31. Case

32. Example:Case… That went fine,,,
• Patient had a lumbar puncture, which demonstrated a slightly elevated white
blood cell count (350 WBC/mm3), elevated protein (145 mg/dL) and decreased
glucose (40 mg/dL) consistent with bacterial meningitis.
• He was admitted and started on intravenous clindamycin, vancomycin and Zosyn
(piperacillin and tazobactam). Anticoagulation also was started, and surgical
drainage of his sinuses was considered but, owing to clinical improvement, was
never pursued. No steroids were used in his treatment.
• Patient remained hospitalized for a week, after which he received outpatient
intravenous antibiotics for approximately two months. Anticoagulation was
continued for seven months until complete resolution of the cavernous sinus
thrombosis.
• His ophthalmic findings resolved, with the abduction deficit being the last
symptom to resolve.
• He suffered no lasting complications.

33. Take Home message
• Septic cavernous sinus thrombosis is an emergency as it can have
devastating complications. It requires an interdisciplinary approach
and immediate aggressive therapy, including the consideration of
steroids, anticoagulation and anaerobic antibiotic coverage.
• Overlooking these subtle indicators and initially pursuing the standard
empiric therapy for orbital cellulitis could significantly delay the
diagnosis with possible detriment to the patient

34. Thank you