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   Table of Contents      
CASE REPORT
Year : 1990  |  Volume : 38  |  Issue : 4  |  Page : 180-181

Cavernous sinus thrombosis with Jacod's triad


1 Ophth. Dept. Dayanand Medical College & Hospital, Ludhiana, India
2 ENT Dept. Dayanand Medical College & Hospital, Ludhiana, India
3 Anatomy Dept. Dayanand Medical College & Hospital, Ludhiana, India
4 Surgery Dept. Dayanand Medical College & Hospital, Ludhiana, India

Correspondence Address:
R N Sud
Ophth. Dept. Dayanand Medical College & Hospital, Ludhiana
India
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Source of Support: None, Conflict of Interest: None


PMID: 2086471

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  Abstract 

Presented is a rare case of cavernous sinus thrombosis of nasal septic origin leading to ophthalmoplegia and blindness of the ipsilateral eye and contralateral visual field involvement. An attempt is made to correlate the aetiopathology with the clinical features.


How to cite this article:
Sud R N, Greval R S, Sud M, Goyal S C. Cavernous sinus thrombosis with Jacod's triad. Indian J Ophthalmol 1990;38:180-1

How to cite this URL:
Sud R N, Greval R S, Sud M, Goyal S C. Cavernous sinus thrombosis with Jacod's triad. Indian J Ophthalmol [serial online] 1990 [cited 2019 Jun 20];38:180-1. Available from: http://www.ijo.in/text.asp?1990/38/4/180/25504


  Introduction Top


Septic cavernous sinus thrombosis is now a rare dis­ease. Blindness as a result of cavernous sinus throm­bosis is uncommon, occuring in less than 10 per cent of cases. [1] Several mechanisms may be implicated. Cor­neal ulceration may occur from failure of lid closure. [2] Occlusion of the central retinal artery may develop from pressure at the orbital apex [3] or as the result of embolium [4] Focal arteritis leading to occlusion of the inter­nal carotid artery may cause ophthalmic artery ischaemia. [5] Toxic neuritis of the optic nerve has been suggested as a possible cause of blindness, secondary to 'adjacent purulent inflammation'. [1] Ischaemic optic neuropathy has been thought to be the cause of blind­ness in a case reported by Friberg and Sogg. [6] However, there is no mention in the literature about the association of Jacod's triad with cavernous sinus thrombosis. In this there is involvement of the cranial nerves II to VI with chiasmal or visual involvement. The syndro rye may be associated with proptosis.

Thrombosis of the cavernous sinus may be due to extension of retrograde thrombosis from various sour­ces. Because of the communications of the cavernous sinus with other venous channels, infection may occur via the orbital veins (as in septic lesions of the face, mouth, pharynx, ear, nose and paranasal sinuses), or as a metastasis in infectious diseases or septic condi­tions. On more than one occasion the tragedy of bilateral blindness has resulted from an event so simple as the injudicious squeezing of a furuncle on the upper lip. [8]


  Case report Top


A 30 year old male patient was admitted in the ENT ward with the chief complaints of fever for 6 days, swelling of the left eye for 3 days and difficulty in swallowing for 2 days prior to admission.

The patient had a furuncle in the left nasal cavity for 7 days. The boil was associated with moderately severe pain. A day after, he started having high-grade fever, not associated with chills or rigors. This was followed by progressive swelling of the upper and lower lids of the left eye for 3 days. He also had mild swelling of the eyelids of the right eye and developed difficulty in swal­lowing for 1 day. Two days after admission, incision and drainage of an abscess of the nasal septum was carried out. About 5 ml. of pus was evacuated. There was no history of previous ocular disease, injury, hypertension or diabetes.

At the time of admission the patient was semicomatose with swelling of both lids of the left eye and the right upper lid. He was referred to the ophthalmologist (3 weeks after admission to the hospital) for loss of vision in the left eye of 1 day duration. General Physical Examination: On the day of ophthal­mic examination the patient was conscious and cooperative, well oriented in time and space, not anaemic, jaundiced or cyanosed. There was neither lymphadenopathy nor oedema. The pulse was 92/ minute and regular. The blood pressure was 130/86 mm. Hg. and the temperature was 98.4° F. Systemic Examination : Revealed nothing abnormal . Ocular Examination : Visual acuity was 6/6 J1 right eye but there was no perception of light in the left eye. Right eye: Showed normal ocular movements, no prop­tosis, but absent consensual pupillary reaction and tem­poral pallor of the optic disc. Visual fields of the right eye showed concentric constric­tion, with lower nasal quadrantic defect. Left eye: Showed no apparent proptosis. There was complete ptosis of the upper lid [Figure - 2] and total ab­sence of ocular movements in all directions [Figure - 3][Figure - 4]. The pupil was semi - dilated amd non-reacting. The trigemin,al nerve function was slightly decreased, with impaired sensation over the forehead and left cheek. The optic disc was pale with clearcut margins and normal optic cup.

Investigation: Blood examination showed leucocytosis with 90 per cent polymorphs. Blood culture showed the growth of Staphylococus aureus. Urine examination showed no abnormality.

Lumbar puncture showed clear fluid under pressure. X-ray of the skull, lateral view did not show any abnor­mality.

C.T. scan of the head was advised, but was refused by the patient on financial grounds.

A diagnosis of cavernous sinus thrombosis of the left side with ipsilateral ophthalmoplegia and blindness and contralateral visual field involvement was made.


  Discussion Top


Ophthalmic signs of fully established canvernous sinus thrombosis include proptosis, chemosis, lid oedema, ophthalmoplegia, retinal venous engorgement (oc­casionally associated with haemorrhages), low- grade optic disc oedema, and at times, generalised retinal oedema, amd even corneal anaesthesia with sub­sequent ulceration. Visual acuity may be reduced during the initial stages as the result of pressure on the retinal artery at the orbital apex.

The signs are unilateral to start with, but the other eye eventually becpmes involved. [9] The commoner signs of cavernous sinus thrombosis are described in textbooks, but there is no mention in the literature about the fundus changes in treated cases of cavernous sinus throm­bosis. The fundus and visual field changes in the present case suggest involvement of the left optic nerve and the optic chiasma . It is possible that ischaemic changes in the left optic nerve and the adjoining part of the chiasma as the result of pressure by the thrombosed cavernous sinus might have occurred. All the above findings may well go in favour of Jacod's triad.

Cavernous sinus thrombosis produces ophthalmoplegia and papilloederna. Primary optic atrophy occurring in cavernous sinus thrombosis is not known. Jacod's triad (the result of pressure on the lateral wall of the cavern­ous sinus) produces ophthalmoplegia, unilateral amaurosis due to optic atrophy, and trigeminal neural­gia.The slightly decreased trigeminal sensation at the time of ophthalmic cheekup could be explained by early return of function during the subsequent recovery of the patient.

It is possible that in the present case the thrombosed cavernous sinus by pressing on the terminal part of the optic nerve and the adjoining part of the optic chiasma had produced optic atrophy on the left side and visual field changes on the right side.

 
  References Top

1.
Shaw R.E. : Cavernous sinus thrombophlebitis. A review. Br. J. Surg. 40 : 40-48, 1952.  Back to cited text no. 1
    
2.
Gupta, M.C. Ahuja, O.P. and Kumar, S. :Cavernous sinus thrombosis. Ind. J. Med. Sci. 24;748-753, 1970.  Back to cited text no. 2
    
3.
Price, C.D. Hamoroff, S. B. and Richards, R.D : Cavernous sinus throm­bosis and orbital cellulitis. South Med. J. 64: 1243-1247. 1971.  Back to cited text no. 3
    
4.
Mehra, K. S. and Somain, P.N. Multiple emboli in central retinal artery following cavernous sinus thrombosis. J. All-Ind. Ophthalmol. Soc. 15:71 - 72. 1967.  Back to cited text no. 4
    
5.
Yarington, C.T. : The prognosis and treatment of cavernous sinus throm­bosis. Ann. Ctol. Rhinol. Laryngol. 70:263-267,1961.  Back to cited text no. 5
    
6.
Friberg,T.R. and Sogg, R.L. : Ischaemic optic neuropathy in cavernous sinus thrombosis. Arch. Ophthalmol. 96:453-456, 1978.  Back to cited text no. 6
    
7.
Williams, Peter, L., Warwick, Roger. Dyson, Mary and Bannister, Lawrence. H.: Gray's Anatomy, Churchill Livingstone, 37th edition, 1989. 802-803.  Back to cited text no. 7
    
8.
Bassey, O.O. and Elebute, E.A.: Septic thrombosis of the cavernous sinus. West Afr. Med. J. 17: 39-41, 1968.  Back to cited text no. 8
    
9.
Parsons, M.: Intracranial venous thrombosis. Post-grend. Med. J. 43: 409-414,1967.  Back to cited text no. 9
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]



 

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