PMC6503816_01
Day 3 marked swelling, erythematous tense right eyelid presented at the first presentation.
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The right eyelid appeared with marked swelling, was tense, with erythema and tenderness and was unable to be opened (Figure 1).
Day 3 (A) axial, (B) coronal CT scan of brain including orbit shows extensive right orbital inflammation with abscess formation, which extended medially from extraconal into intraconal space posterior to eyeball (arrow head).
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Day 3 (A) coronal and (B) axial T1W with fat suppression MRI scan of brain including orbit showed multiple hyposignal intensity areas with rim-enhancement in preseptal and intraconal spaces. The right superior ophthalmic vein thrombosis is suspicious by intraluminal filling defect with rim-enhancement (star) showing in (C and D) coronal view.
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Magnetic resonance imaging (MRI) with contrast of the brain and orbit (Figure 3) showed multiple small lesions of hyposignal intensity and rim-enhancement occupying at preseptal and intraconal regions. The right superior ophthalmic vein thrombosis was suspicious by the evidence in coronal MRI (Figure 3C and D) showing no intraluminal contrast filling with rim enhancement.
Day 7 limitation of extraocular movement of the right eye in (A) primary position, (B) left gaze, (C) right gaze, (D) up gaze, and (E) down gaze are demonstrated.
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Follow-up MRI brain and orbit with contrast on the fourth days after tertiary care admission was performed to rule out cavernous sinus thrombosis, as physical examination found no improvement of limitation of extraocular movement corresponding to cranial nerve 3, 4 and 6 paresis (Figure 4).
Color fundus photographs show (A) day 5 retinal whitening with scattered flame-shaped retinal hemorrhage, attenuated retinal arteries and venous dilatation representing combined central retinal artery and vein occlusion. There is optic disc swelling. The cilioretinal artery presenting with retinal whitening along the vessel demonstrates cilioretinal artery occlusion. (B) Day 10 a week after treatment by canthotomy and cantholysis to relieve orbital pressure, optic disc swelling, retinal swelling and whitening decreases. However, there is obvious evidence of a macular hole.
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She developed a shaggy-edge macular hole 5 days after initial fundus assessment (Figure 5).
Day 10 fundus photograph shows (A) retinal whitening and hemorrhage in the macular area with macular hole. Cilioretinal artery is occluded (star). (B) Late phase of fluorescein angiography overlying on the fundus photograph reveals vascular filling defect of the arteries around the macula including cilioretinal branch (star).
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It also demonstrated that the shaggy-edge window defect angiographic pattern at the macular area consisted of a macular hole (Figures 6 and 7).
Day 10 fluorescein angiography in the early phase, (A and B) show delayed arterial filling, taken 10 seconds apart. (C) Vascular filling defect and perivascular leakage are detected in late phase with window defect of macular hole. Optical coherence tomography (OCT) corresponding to the upper section on (C) angiography depict (D) the inner retina thickening. This represents inner retinal swelling due to ischemia causing by arterial occlusion. (E) OCT passing the macular on (C) angiography reveals macular hole with the present of posterior hyaloid membrane. Thin strands connecting vitreous and retinal surface are demonstrated, confirming that the macular hole might be from ischemic process rather than traction force.
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It also demonstrated that the shaggy-edge window defect angiographic pattern at the macular area consisted of a macular hole (Figures 6 and 7). Optical coherence tomography (OCT) depicted thickening hyper-reflective inner retinal layer (Figure 7D) and macular hole with present of posterior hyaloid membrane (Figure 7E).
Timeline of case.
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Important information from the patient was organized as a timeline (Figure 8).