Acute ophthalmic artery obstruction secondary to subperiosteal abscess with retrobulbar phlegmonous infection

A 57-year-old diabetic woman experienced a sudden severe visual loss and total ophthalmoplegia in her left eye. Magnetic resonance imaging studies showed orbital cellulitis, located mainly in the posterior orbit, secondary to ethmoid and maxillary sinusitis. Fundus examination and fluorescein angiograms were suggestive of left ophthalmic artery occlusion. Subsequent ethmoidectomy and incisional biopsies failed to show any specific microorganism, particularly mucormycosis. This case represents an unusual complication of orbital subperiosteal abscess with retrobulbar phlegmonous infection which left the patient with no light perception as a result of ophthalmic artery obstruction. Posterior orbital infections should be more closely monitored and surgery should be considered in early stages of the disease.     

Orbital Cellulitis in Children—Medical Treatment Versus Surgical Management

Introduction: Ophthalmologists differ in their threshold for surgical management in paediatric patients with orbital cellulitis. We studied the management choices and outcome of children admitted with this disorder. Material and Methods: A retrospective review was performed on patients with orbital cellulitis admitted between January 2001 and December 2004 to a tertiary paediatric referral centre in Singapore. The patients were studied for age, associated systemic disease, medical treatment, drainage procedure undertaken, organism isolated and outcome. Statistical methods were applied for comparing medical treatment with surgical treatment with respect to recovery time, recurrence, and time between the presentation of patient and initiation of treatment. Results: Twenty patients were studied. Average age was 5.5 years. 5/20 (25%) had a preceding history of upper respiratory tract infection. From CT findings, we came to know that 3/20 (15%) were due to isolated ethmoiditis, 5/20 (25%) had obstruction of the osteomeatal complex of the paranasal sinuses, 2/10 (10%) had intracranial abscesses due to frontal sinusitis. 4/20 (20%) had all 4 ipsilateral paranasal sinuses infected. 2/20 (10%) had preseptal cellulitis with posterior extension into the orbit. 2/20 (10%) had orbital cellulitis related to dacryoadenitis and 2/20 (10%) had pansinusitis with orbital soft tissue stranding. 13/20 (65%) had orbital and /or endoscopic drainage. The remainder of the patients had good immediate response to sole medical treatment and did not require surgery. The most commonly isolated organism was Staphylococcus aureus 5/20 (25%). All patients recovered within a mean of 9.6 days with no complications or functional deficit. Conclusions: Paediatric orbital cellulitis can be treated conservatively or with surgical drainage. Indications for surgery include pansinusitis, large abscesses with significant mass effect, concurrent intracranial involvement, poor response to initial medical treatment and the presence of an orbital abscess and gas. Sole medical treatment worked well in children with no orbital abscess, small or medial abscesses as they tend to have a single organism infection. This is also of particular significance in young children below the age of one where endoscopic surgery can be technically difficult. Intracranial involvement occurred in association with frontal sinusitis and affected patients had the longest duration of hospitalization.     

新生儿继发于筛窦炎的眼眶脓肿(英文)

骨膜下脓肿是眼眶蜂窝织炎的一种,以脓和渗出液汇集在眼眶内骨膜下为特点。对于新生儿,眼眶脓肿非常罕见。我们报告1例年龄为26d的右眼患有严重眼眶蜂窝织炎的女患儿。眼眶和副鼻窦CT扫描显示右眼眶蜂窝织炎并内侧骨膜下和眼眶后部脓肿。眼分泌物培养见葡萄球菌生长,经用先锋霉素和甲硝唑静脉注射和经内窥镜鼻窦手术行急诊脓肿引流,恢复良好。通过内窥镜的鼻窦引流手术是预防更严重的并发症的首选治疗。     

Orbital cellulitis complicating strabismus surgery: a case report and review of the literature.

Orbital cellulitis is a rarely reported, but potentially vision- and life-threatening complication after strabismus surgery. To date, only seven cases of orbital cellulitis complicating strabismus surgery have been reported in the world literature, and only two cases were reported in adult patients, both occurring more than 100 years ago. We describe a case of unilateral orbital cellulitis after bilateral strabismus surgery in an adult. Early diagnosis (aided by computed tomography) and aggressive intravenous antibiotic therapy resulted in a favorable visual outcome. Diagnosis and management are discussed, and this case is compared with previous cases in the literature.     

Blinding orbital cellulitis: a complication of strabismus surgery

A 56-year-old healthy man underwent left medial rectus recession and lateral rectus resection for esotropia. The next day he developed severe left periocular pain with decreased vision, an afferent pupillary defect, periorbital edema, limited ocular motility, and proptosis. Computed tomography showed fat stranding and less than 90 degrees of posterior globe tenting. Despite intravenous antibiotics to treat orbital cellulitis, and a lateral canthotomy and cantholysis to decompress the orbit, visual acuity worsened to no light perception. The patient underwent emergent orbital decompression including release of the superior and inferior septum and outfracturing of the orbital floor and medial wall; however, there was no recovery of vision. Blinding orbital cellulitis is a rare complication after strabismus surgery. Despite poor prognosis, prompt diagnosis and aggressive treatment may maximize visual potential.     

Orbital Cellulitis After Strabismus Surgery

Serious infection is uncommon after eye muscle surgery. Orbital cellulitis is a rarely reported but is potentially vision- and life-threatening complication after strabismus surgery. In this report, we describe a case of unilateral orbital cellulitis after strabismus surgery for sensory exotropia in a healthy adolescent boy.     

Orbital complications after aqueous drainage device procedures

A retrospective case series of 2 patients with orbital complications after tube shunt placement for glaucoma is reported. The first patient presented with limited motility and conjunctival injection in the setting of intraocular gas leakage in the superior orbit after previous vitreoretinal surgery. The second patient presented with multiple signs of orbital cellulitis. Both patients improved with intravenous antibiotics. Although rare, orbital complications may occur after glaucoma tube shunt surgery.     

Periorbital cellulitis in children: Analysis of outcome of intravenous antibiotic therapy

Periorbital cellulitis is a relatively common ocular disease in the pediatric population. Early diagnosis of this disease with a prompt intervention is critical to avoid vision and life-threatening complications. In the last years, medical therapy has been expanding for the treatment of orbital cellulitis, instead of the standard surgical approach. The purpose of this study was to describe the outcome of treatment with intravenous antibiotic of periorbital cellulitis in children. A retrospective review of all children admitted with periorbital cellulitis in our hospital between January 2002 and July 2013 was conducted. Cases were divided in two subgroups, pre-septal and post-septal infection. The demographics, clinical findings, treatment and outcomes were analyzed. In total 110 children were included, 93 with pre-septal and 17 with post-septal cellulitis. The mean age was 3.5 years in children with pre-septal cellulitis and 5.5 years in those with post-septal cellulitis (p = 0.149). For both subgroups the most common predisposing factor was sinusitis. Intravenous antibiotic therapy was successful in all except one patient with an orbital abscess who required surgical intervention. In our study complete recovery was achieve in all (except for one) children with periorbital cellulitis treated with intravenous antibiotics only.     

Anaerobic orbital cellulitis

A 10-year-old boy with orbital cellulitis died seven weeks after admission to the hospital despite intensive surgical intervention and medical therapy. We isolated many anaerobic bacteria from the orbit, frontal sinus, and epidural space. Orbital cellulitis, which often occurs by direct extension from infected paranasal sinuses, commonly affects children and young adults, and is a potentially lethal disease, if left untreated. Heightened awareness of the role of anaerobes in chronic sinusitis and of the possibility of an anaerobic orbital cellulitis may lead to the identification of more cases. Penicillin G appears to be the first drug of choice in cases with suspected anaerobic orbital cellulitis. Chloramphenicol and clindamycin should be considered, if treatment with penicillin fails. Antibiotics alone should not be considered as a panacea, and surgical drainage is often the most compelling consideration.     

Intracranial infection associated with preseptal and orbital cellulitis in the pediatric patient

PURPOSE: To identify risk factors in children admitted with preseptal or orbital cellulitis with associated intracranial infection. METHODS: A retrospective chart review identified 10 patients (< or = 18 years) with a diagnosis of preseptal or orbital cellulitis and a concurrent or subsequent diagnosis of intracranial infection. RESULTS: Diagnoses confirmed by imaging included sinusitis (n = 10), preseptal cellulitis (n = 4), orbital cellulitis (n = 6), orbital subperiosteal abscess (n = 5), Pott's puffy tumor (n = 4), epidural empyema (n = 2), epidural abscess (n = 6), and brain abscess (n = 2). The timing of diagnosis of intracranial infection ranged from hospital day 1 to 21. All but 1 patient had positive microbial cultures. Seven of 10 patients had positive microbial cultures from two or more sites, 70% of which were polymicrobial; Streptococcus species and Staphylococcus species were the most commonly isolated bacterial pathogens. All patients required both medical and surgical therapy; all 10 patients underwent sinus surgery; 8 patients required neurosurgical craniotomy; and 5 patients underwent orbital surgery. There were no deaths. CONCLUSION: Intracranial involvement should be suspected in any patient age > or = 7 years with preseptal or orbital cellulitis associated with orbital subperiosteal abscess, Pott's puffy tumor, concurrent sinusitis, complaints of headache, and continuing fever despite intravenous antibiotics. Given the high incidence of polymicrobial infection found on cultures in this series, broad-spectrum antibiotics are strongly indicated. When imaging the orbits and sinuses in such patients, we recommend including the brain to rule out intracranial involvement.     

Orbital pseudotumor after an upper respiratory infection: a comprehensive review

BackgroundIdiopathic orbital inflammation (IOI), also known as orbital pseudotumor, is a nonspecific orbital inflammation of unknown etiology. IOI can clinically mimic many other orbital pathologies, some of which can be life-threatening, as in the case of orbital cellulitis. Thus, it is imperative for the clinician to emergently arrive at the correct diagnosis. In many cases, however, IOI presents as a clinical and therapeutic challenge, and conclusive diagnosis is only confirmed after all other etiologies have been ruled out.Case ReportA 63-year-old man presented urgently with a red, proptotic, painful eye. After history, blood tests, radiologic testing, and ruling out other emergent etiologies, such as orbital cellulitis, the patient was placed on oral steroids. He responded immediately to the steroid treatment. However, the patient did have a recurrence. With the second IOI episode, the patient noted, as previously, a preceding upper respiratory infection. This case may possibly show an association between an infectious trigger leading to a nonspecific aberrant immune response in the orbit.ConclusionIOI is a difficult condition to diagnose and treat. After ruling out other orbital pathologies, it is appropriate to begin treatment with oral steroids. In this case report, the patient noted an upper respiratory infection before each episode of IOI. Although there is no proof of cause, there is a strong case for the consideration of a viral respiratory infection leading to IOI.     

Cost-Related Antibiotic Dosage Omissions—Challenge for Orbital Cellulitis Management in Resource Poor Communities

Background: Orbital cellulitis is a medical emergency with potential vision and life threatening complications. Aim: To highlight clinical presentation and challenges in the management of orbital cellulitis in resource poor communities of southwestern Nigeria. Method: Retrospective review of patients managed for orbital cellulitis at the Wesley Guild Hospital, Ilesa, Nigeria for biodata, socioeconomic status, clinical presentation, compliance to prescribed medications and treatment outcome. Data was analyzed using SPSS version 11. Result: Seventeen patients with mean age and standard deviation of 10 ± 9.9 years were managed for orbital cellulitis. Thirteen (76.5%) females and 4(23.5%) males giving a male to female ratio of 1:3.3 (p = 0.03). Most patients (94.1%) belonged to low socioeconomic status and sinusitis was the most common predisposing factor. 10 (58.8%) had intravenous antibiotics only while 7(41.2%) had surgical drainage of abscess in addition. Delayed and irregular administration of antibiotics was observed in 9 (52.9%) patients due to lack of funds thus necessitating change of choice in antibiotics. Complication include ptosis 3(17.6%), corneal opacity 2 (11.8%), optic atrophy 1(5.9%) and 1(5.9%) meningitis and death 1(5.9%). Conclusion: Cost and affordability should be major determinants of choice of empirical antibiotics in resource poor communities to ensure timely and regular treatment and improve prognosis in management of orbital cellulitis.     

眼眶骨折伴斜视患者的临床诊治分析

目的 分析眼眶骨折伴斜视患者的斜视性质、眼眶骨折修复的手术时机和术后斜视的变化等.方法 回顾分析2001年1月到2008年12月在中山大学中山眼科中心诊治的眼眶骨折患者.常规作眼眶CT检查、被动转动试验、眼位和眼球运动检查、复像试验,观察眼眶骨折修复前后眼位和眼球运动情况等.结果 共87例90只眼,男性66例,女性21例;年龄3～68岁(平均30.6岁);右眶27例,左眶57例,双眶3例.36%的患者有视力受损.32%为眼眶爆裂性骨折,68%为复合性骨折;以内壁和下壁骨折多见.术前47%的患者有斜视,其中麻痹性41.5%,限制性58.5%;眼眶骨折修复后:35例术前有斜视者(平均随访1年),28.6%斜视消失;17.1%正前方和下方功能位置无斜视,37.1%斜视部分好转或不变;17.1%斜视加莺;1例术前无斜视,术后出现医源性斜视.结论 眼眶骨折伤后患眼斜视的性质包括麻痹性和限制性,骨折修复手术时机存在争论,以下情形需要尽快手术:(1)影像学检查显示有眼外肌断裂;(2)CT扣描和被动转动试验均示有明确的眼外肌嵌顿,保守治疗二周无好转;(3)外壁和上壁的Blow-in骨折.眼眶骨折修复术后其斜视既可消失也可不变或加重;医源性斜视要尽量避免.     

眼眶骨折伴斜视患者的临床诊治分析

目的 分析眼眶骨折伴斜视患者的斜视性质、眼眶骨折修复的手术时机和术后斜视的变化等.方法 回顾分析2001年1月到2008年12月在中山大学中山眼科中心诊治的眼眶骨折患者.常规作眼眶CT检查、被动转动试验、眼位和眼球运动检查、复像试验,观察眼眶骨折修复前后眼位和眼球运动情况等.结果 共87例90只眼,男性66例,女性21例;年龄3～68岁(平均30.6岁);右眶27例,左眶57例,双眶3例.36%的患者有视力受损.32%为眼眶爆裂性骨折,68%为复合性骨折;以内壁和下壁骨折多见.术前47%的患者有斜视,其中麻痹性41.5%,限制性58.5%;眼眶骨折修复后:35例术前有斜视者(平均随访1年),28.6%斜视消失;17.1%正前方和下方功能位置无斜视,37.1%斜视部分好转或不变;17.1%斜视加莺;1例术前无斜视,术后出现医源性斜视.结论 眼眶骨折伤后患眼斜视的性质包括麻痹性和限制性,骨折修复手术时机存在争论,以下情形需要尽快手术:(1)影像学检查显示有眼外肌断裂;(2)CT扣描和被动转动试验均示有明确的眼外肌嵌顿,保守治疗二周无好转;(3)外壁和上壁的Blow-in骨折.眼眶骨折修复术后其斜视既可消失也可不变或加重;医源性斜视要尽量避免.     

Late recurrence of unilateral graves orbitopathy on the contralateral side

PURPOSE: To report a case of late recurrence of unilateral Graves orbitopathy on the contralateral side after 7 years. DESIGN: Interventional case report. METHODS: A 44-year-old woman with left unilateral Graves orbitopathy underwent two-wall orbital decompression on the left side. After strabismus surgery and left upper eyelid surgery, she was discharged. RESULTS: Seven years after discharge, the patient developed Graves orbitopathy on the right side, and she underwent two-wall orbital decompression on the right side. CONCLUSION: At least in patients with unilateral Graves orbitopathy, late recurrence of the disease in the contralateral orbit may occur.     

Esophageal Adenocarcinoma and Urothelial Carcinoma Orbital Metastases Masquerading as Infection

Orbital metastases can masquerade as other orbital processes. We present two cases of orbital metastases, the first being the first reported adenocarcinoma of the esophagus presenting as an orbital metastasis prior to the primary being known, and the other as the first urothelial carcinoma to present as orbital cellulitis. The first patient presented with left upper eyelid pain. CT scan identified a superolateral subperiosteal fluid collection without concomitant sinus disease, which was drained in the operating room. Two weeks later repeat CT scan showed recurrent orbital subperiosteal fluid. It was drained and a biopsy showed necrotic adenocarcinoma. The second case presented with a painless right proptosis, decreased vision, and globally decreased ocular motility 3 days after bladder resection for urothelial carcinoma. CT scan demonstrated pan sinusitis with a soft tissue mass in the apex of the right orbit with extension through the superior orbital fissure. After no improvement on antibiotics endoscopic drainage was performed. Pathology revealed metastatic urothelial carcinoma within the orbital fat.     

Periorbital and orbital cellulitis before and after the advent of Haemophilus influenzae type B vaccination

OBJECTIVE: To evaluate the effect of the introduction of the Haemophilus influenzae B (Hib) vaccine (introduced first in 1985, then extended in 1990 to children at least 2 months of age) on the epidemiologic features of periorbital and orbital cellulitis. DESIGN: Retrospective, comparative case series. PARTICIPANTS: Three hundred fifteen pediatric inpatients. METHODS: Children at Massachusetts General Hospital and Massachusetts Eye and Ear Infirmary with discharge diagnosis of periorbital or orbital cellulitis from 1980 through 1998 were reviewed. MAIN OUTCOME MEASURES: Case rate, culture-positive isolates, and associated conditions. RESULTS: A total of 297 cases of periorbital cellulitis and 18 cases of orbital cellulitis were reviewed. Before 1990, there were 27 cases of Hib-related cellulitis (11.7% of total in that period), whereas after 1990, there were only three (3.5% of total; P = 0.028). The number of cases per year was significantly lower after 1990 (21.2 +/- 10.4 vs. 8.7 +/- 3.9; P = 0.008), as were the number of positive culture isolates (for any organism) after 1990 (76 [33. 0%] vs. 9 [10.6%]; P < 0.001). The medical conditions most commonly associated with periorbital cellulitis were sinusitis (44 [14.5%]) and upper respiratory infections (73 [26.6%]). All cases of orbital cellulitis were associated with sinusitis. CONCLUSIONS: The introduction of the Hib vaccine coincided with a sharp decline not only in the number of periorbital and orbital cellulitis cases related to H. influenzae, but also in the annual case rate. These data are consistent with a facilitative role for H. influenzae in the development of cellulitis secondary to other pathogens. They also may support restriction of the spectrum of antibiotics used to manage these conditions.     

Successfully treated rare presentation of orbital me- lioidosis

AIM: To report a rare case of melioidosis presenting as orbital abscess, who was successfully treated with high dose of intravenous ceftazidime. METHODS: A case report. RESULTS: A 55-year-old Malay gentlemen who was newly diagnosed with diabetes mellitus, presented with prolonged low grade fever for three weeks and left eye swelling for five days duration. Initial CT scan of brain and orbit showed left periorbital cellulitis and acute left sphenoidal sinusitis. Initial swab culture grew Pseudomonas sp. His general condition improved with regular antibiotics. However, upon completion of intravenous therapy his condition worsened and the left eye became more proptosed. Repeat CT scan of the brain and orbit showed left eye orbital abscess with intracranial exten-sion. Swab culture from fistula of the lateral part of upper eyelid showed Burkholderia pseudomallei. He was treated with high dose of intravenous ceftazidime, oral co-trimoxazole for the acute management and on maintenance dose of oral co-trimoxazole for 2 months. He responded well to treatment and had no relapse up to one year post treatment. Unfortunately his left eye vision was not salvageable. CONCLUSION: This case illustrates a rare presentation of orbital abscess due to melioidosis which was complicated with cerebral abscess and septicemia. An accurate diagnosis was essential and high dose of susceptible antibiotics was important for the institution of therapy to successfully treat this potentially fatal condition.     

成功治疗罕见的眼眶类鼻疽1例(英文)

目的:报告1例罕见的以眼眶脓肿为主要表现,大剂量头孢他定静脉给药治疗成功的类鼻疽。方法:眼眶类鼻疽病例报告1例。结果:一名55岁的马来人,新近诊断为糖尿病,低热3wk,左眼肿胀5d入院。头颅及眼眶CT显示左眼眶蜂窝织炎和左侧急性蝶窦炎,最初上眼睑瘘管拭子培养结果为假单胞菌属,给予常规抗生素治疗,患者的全身情况改善。然而随着持续静脉给药,患者全身情况开始恶化,左眼变得更加突出,复查头颅及眼眶CT显示左眼眶脓肿并颅内扩散形成脑脓肿。来自上眼睑侧部瘘管的拭子培养结果显示类鼻疽假单胞菌,急性期采用大剂量头孢他定静脉治疗并口服复方增效磺胺,后采用复方增效磺胺维持治疗2mo治愈,观察1a未见复发。不幸的是患者的左眼视力丧失。结论:这是1例罕见的由类鼻疽引起的伴发脑脓肿和败血症的眼眶脓肿。在正确诊断的前提下,同时应用大剂量敏感抗生素可有效治疗这种严重疾病。     

儿童眶周和眼眶蜂窝织炎的临床分析

目的:探讨儿童眶周和眼眶蜂窝织炎的临床特点及治疗方法。方法:对2010年本院收治的54例眶周和眼眶蜂窝织炎患儿的临床资料进行回顾性研究。结果:儿童眶周蜂窝织炎34例,眼眶蜂窝织炎20例,平均男女比例2.6∶1,3岁以下发病比例达71%。两者发病季节高峰分别在11月份和1月份,发病原因多样化。眶周蜂窝织炎的外周血白细胞计数、中性粒细胞计数及血清C反应蛋白(CRP)升高比例低于眼眶蜂窝织炎,差异有统计学意义(P<0.01)。57%眶周蜂窝织炎和88%眼眶蜂窝织炎患儿CT检出鼻窦炎。眼部脓肿的脓液培养得到金黄色葡萄球菌、模仿葡萄球菌和肺炎链球菌。眶周蜂窝织炎可用单一或二联抗生素治疗,眼眶蜂窝织炎常需抗生素联合用药,必要时实行手术。结论:儿童眶周蜂窝织炎和眼眶蜂窝织炎的发病年龄集中在3岁以下,秋冬季为高发季节,上呼吸道感染和鼻窦炎是主要病因。眼眶蜂窝织炎比眶周蜂窝织炎感染重,CT有利于临床诊断,抗生素应覆盖葡萄球菌和链球菌,并根据病因和微生物学检查调整用药,在适宜时期实行手术可以加快治愈并减少复发。