A 57 y.o. male comes to triage with a chief complaint of decreased vision in the R eye
What could be wrong?
hint: the pt has had a gradual decrease in vision for six months.
Our patient had bilateral cavernous sinus thrombosis. When our patient first arrived his eye pressure was recorded as high and a lateral canthotomy was done. There was no change in eye pressure. A dense corneal opacity was initially thought to be endophthalmitis but remained unchanged throughout his hospital stay. Marked corneal thinning was noted and a tarsorrhaphy was performed. He remains in the hospital and has declined enucleation. He has no light perception in the eye. He has renal failure is on dialysis, has dm and Enterobacter Faecalis bacteremia. He had colonic thickening thought to be colon ca but has declined colonoscopy. He was treated with antibiotics for his gram neg sepsis and heparin.
cranial nerve abnormalities are often seen with caverous sinus thrombosis
Causes of increased intraocular pressure include:
Glaucoma- which may have a genetic predisposition( open angle or angle closure) or be caused by a hyphema after trauma.
Cavernous sinus thrombosis- can increase ocular pressure causing significant chemosis and proptosis.
Carotid cavernous fistula- which can occur after trauma and be either high flow or low flow.
Medication side effects- steroids and succinylcholine can cause increased eye pressure. It has been reported after LASIK surgery when steroids are given.
Playing brass and woodwind instruments- can increase intraocular pressure transiently. Brass instrument players showed a significant elevation after playing high and middle frequency tones.
Our patient has not had improvement after antibiotics for preseptal cellulitis
The take home message is that lateral canthotomy is not always the answer to increased eye pressure. Recently a soft ball player came to the ED with decreased vision after being hit in the L eye by a line drive. She had multiple orbital fractures and an eye pressure of 40. Initially, a canthotomy was considered, but it was recognized that a microhyphema was the most likely cause of her increased eye pressure and she was managed conservatively.
Visvanathan V, Uppal S, Prowse S. Ocular manifestations of cavernous sinus thrombosis. BMJ Case Rep. 2010;2010:rbcr0820092225.
Ladner T, Davis B, He L. et al. Transorbital superior ophthalmic vein sacrifice to preserve vision in ocular hypertension from aseptic cavernous sinus thrombosis. BMJ Case Rep 2014;2014 bcr 2014011454.
Schmidtmann G. Intraocular pressure fluctuations in professional brass and woodwind musicians during common playing conditions. 2011 Graefes Arch Clin Exp Ophthalmol