Orbital cellulitis

Valsalva-associated orbital compartment syndrome in the setting of frontoethmoidal mucocele and orbital cellulitis

Valsalva-associated orbital compartment syndrome in the setting of orbital cellulitis, mucocele, or subperiosteal abscess has not been previously reported. A previously healthy girl presented with orbital cellulitis complicated by a subperiosteal abscess and frontoethmoidal mucocele. On the day of her planned orbitotomy and endoscopic sinus surgery, she developed a Valsalva-associated retrobulbar hemorrhage and elevated intraocular pressure after crying during a blood glucose fingerstick. An urgent canthotomy and cantholysis in addition to the planned endoscopic sinus procedure was performed. She did well post-operatively with normal vision at follow-up. Based on these experiences, there should be a consideration to implement heightened vigilance to prevent or minimize Valsalva maneuvers in orbital cellulitis patients with subperiosteal abscesses or mucoceles extending into the orbit. While it remains unclear whether and to what degree these patients may be at an increased risk of developing retrobulbar hemorrhage leading to orbital compartment syndrome, we hope that this novel report aids in providing another consideration with the goal of preventing vision loss.

Orbital cellulitis: Key information for nurses

ABSTRACT

Cellulitis is a soft tissue infection that presents with erythema, swelling, and pain. When the site of infection is around the eye, it is an ocular emergency. Recognizing orbital cellulitis and understanding its significance can lead to prompt treatment and prevention of untoward patient outcomes.

Orbital aspergillosis in an immunocompromised man with no history of trauma: a case report

Fungal orbital cellulitis is usually seen in immunocompromised individuals, and opportunistic pathogens are the main etiology. We herein report a case of fungal orbital cellulitis due to Aspergillus in a patient with no history of trauma. A 48-year-old man presented to the emergency room of our hospital with a 2-week history of periorbital swelling, conjunctival hyperemia, and chemosis of his right eye. The visual acuity of his right eye was 6/20, and the intraocular pressure was 44 mmHg. The main clinical findings were proptosis of the right ocular globe with conjunctival hyperemia and a palpable infratemporal orbital mass. Laboratory testing failed to detect the presence of a pathogenic infection, and the lesions on computed tomography images resembled those of a malignant tumor of the orbit. The diagnosis was finally confirmed by postoperative pathological examination, and the patient responded favorably to debridement combined with antifungal therapy. Histopathological examination may help to reveal the nature of this disease. Surgical removal of inflammatory lesions can serve as an important diagnostic and treatment method for fungal orbital cellulitis.

Qualitative and Quantitative Magnetic Resonance Imaging in Bacterial Orbital Cellulitis

PURPOSE

To summarise the qualitative and quantitative parameters of bacterial orbital cellulitis (OC) on magnetic resonance imaging (MRI) and explore their clinical correlations.

METHODS

Multi-centre retrospective study with inclusion of patients of all ages with OC who underwent MRI. Patients with isolated pre-septal cellulitis, bilateral disease and poor-quality scans were excluded. An enlargement ratio for extraocular muscles (EOMs) was calculated by dividing maximal EOM measurements from the affected side by the contralateral side.

RESULTS

Twenty MRI scans from twenty patients (Mean age: 40.8 ± 24.3 years old, M: F = 15:5) between 2011 and 2022 were analysed. Three (15.0%) cases were paediatric patients (<18 years old). All cases had both pre-septal and orbital fat involvement. The EOM were affected in nineteen cases, with the superior muscle complex (18/19, 94.7%) most commonly affected. Mean enlargement ratio (1.30, Range: 1.04-1.82) was greatest for the medial rectus on axial views on T1 and fat-suppressed contrast-enhanced T1 (FS CE T1). Optic peri-neuritis was present in eleven (55.0%) patients, whilst two (9.5%) cases had optic neuritis. A greater degree of proptosis was observed in patients with optic neuropathy and those who underwent surgical intervention compared to those without (p = .002 and p = .002, respectively).

CONCLUSION

MRI remains an important imaging modality for evaluating complicated OC. However, qualitative features may lack accuracy and is not a reproducible means of analysis. Simple quantitative parameters, such as proptosis and EOM measurements, correlate with high-risk clinical features and may have utility in predicting clinical course.

Septic Cavernous Sinus Thrombosis: Clinical Characteristics, Management, and Outcomes

BACKGROUND

Septic cavernous sinus thrombosis (CST) is a rare condition traditionally associated with high morbidity and mortality. More recent case series report more favorable outcomes, including full functional recovery. A comprehensive assessment of the clinical characteristics and prognostic factors of visual and survival outcomes in septic CST is warranted to contemporize current understanding and help guide management.

METHODS

A multicentered retrospective cohort study was conducted at 2 tertiary care centers using an electronic medical record search of the term, "thrombosis of cavernous venous sinus" between January 1, 2000, and December 31, 2021. Inclusion criteria consisted of active infection and radiographic evidence of associated CST. Demographic and clinical data extracted included age at presentation, sex, infection type and extent, and ophthalmic examination findings at presentation-best-corrected visual acuity (BCVA), presence of relative afferent pupillary defect (RAPD), intraocular pressure (IOP), and extraocular motility (EOM) limitation. Management data collected consisted of type and length of antimicrobial therapy, type and length of anticoagulation administration, and surgical intervention. Primary outcomes assessed were ophthalmic examination findings at final evaluation and same-hospitalization mortality.

RESULTS

A total of 27 patients with imaging-confirmed septic CST were identified at 2 tertiary care centers. At presentation, 2 (8.7%) patients had no light perception (NLP) vision, 8 (29.6%) patients had RAPD, 17 (73.9%) patients had EOM limitation, and 13 (54.2%) had IOP >21 mm Hg. All patients received antimicrobial therapy, with vancomycin being the most common agent. Fifteen patients (55.6%) received anticoagulation, and 21 (81.5%) patients underwent surgical intervention. Same-hospitalization mortality was 3 (11.1%). Among the 21 patients with ophthalmic data at follow-up, 3 (16.7%) had NLP vision, 5 (23.8%) had a persistent RAPD, 7 (31.8%) had persistent EOM limitation, and no patients had IOP elevated above 21 mm Hg. Patients with RAPD at presentation had significantly worse BCVA at final evaluation (logMAR BCVA 1.43 higher on average, P = 0.01) and a significantly higher mortality rate (37.5% vs. 0.0%, P < 0.01) than non-RAPD patients. Demographic features, BCVA at presentation, EOM limitation at presentation, elevated IOP at presentation, and comorbid orbital cellulitis were not associated with worse visual or mortality outcomes.

CONCLUSIONS

Septic CST may result in permanent ophthalmic functional deficit in almost one-third of cases and mortality in approximately 11% of patients under contemporary management. New RAPD at presentation may indicate higher risk of poor visual and survival outcomes.

Orbital Fat Density as a Diagnostic Tool in Pre-Septal and Orbital Cellulitis

PURPOSE

To evaluate the usefulness of measuring orbital fat density in identifying post-septal involvement when initial differential diagnosis between orbital and periorbital cellulitis (OC and POC) is unclear.

MATERIALS AND METHODS

Retrospective study of patients with clinical diagnosis of OC or POC who underwent contrast-enhanced computerized tomographic scans over a span of 10 years. Intraconal orbital fat density was measured with Hounsfield units (HU) in six areas on axial scans consisting of nasal and temporal intraconal sites. These measurements correlated with the initial and final diagnoses. Main outcome measures were HU values at the initial and final diagnoses.

RESULTS

Fifty-seven patients were included. Mean HU measurement was -52 ± 18 HU for the involved side vs. -63 ± 13 for the uninvolved side (P < .001). The values were higher in cases of a final diagnosis of OC in the involved side (P < .001). The HU values were significantly higher in the nasal vs. the temporal locations of each orbit bilaterally (P < .001). The initial POC diagnosis of 20 patients (35%) was revised to OC.

CONCLUSION

Intraconal fat density measurements can assist in the primary assessment of orbital involvement in patients with an uncertain initial diagnosis, with a HU value higher than -50 is suggestive of orbital involvement.

Reconstruction of Orbital Wall Fractures with a Combination of Resorbable Plates and Antibiotic-Impregnated Collagen Sheets

(1) Background: Orbital wall fractures are common in maxillofacial trauma, and artificial implants are often used for reconstruction. However, there has always been concern about infection because implants are directly exposed to the airway. This study was conducted to determine the effectiveness of a combination of resorbable plates and antibiotic-impregnated collagen sheets in reconstructions of orbital fractures and to determine whether it had an effect in reducing postoperative antibiotic use. (2) Methods: The retrospective study was conducted on 195 patients who underwent orbital wall reconstruction from March 2019 to August 2022. The 176 patients in the control group underwent reconstruction using only resorbable plates and were administered postoperative antibiotics for 5 to 7 days. On the other hand, the 19 patients in the experimental group underwent reconstruction using a combination of resorbable plates and antibiotic-impregnated collagen sheets and only received antibiotics once before surgery. The occurrence of ocular complications, the length of hospitalization, the infection incidence rate, and the adverse effects of antibiotics were investigated. (3) Results: significant ocular complications were observed in the experimental group during a follow-up period of more than 1 year. Regarding postoperative infections, there were two cases of infection in the control group (infection rate: 1.14%), while no infection was found in the experimental group. The hospitalization period of the experimental group was significantly shorter than that of the control group (p < 0.01), and the incidence of total adverse effects of antibiotics, especially nausea, was lower in the experimental group (p = 0.02). (4) Conclusions: The combined use of resorbable plates and antibiotic-impregnated collagen sheets allows effective orbital wall reconstruction without infection, with a shorter hospital stay, and with fewer antibiotic adverse effects.

A Review of Pediatric Ophthalmic Tumors

Tumors of the eye, orbit, and ocular adnexa can arise in the pediatric population. These entities can be both vision- and life-threatening and may be associated with systemic disease. Given their relative rarity, pediatricians must be aware of these conditions and understand what findings warrant immediate referral to an ophthalmologist for initiation of further testing. We aimed to review these conditions and highlight clinical features to promote awareness and expedite diagnosis. Tumors are subdivided into the following categories for review: anterior tumors of the eyelid and ocular surface, orbital tumors, and intraocular tumors.

Neutrophil-to-Lymphocyte Ratios Distinguish Idiopathic Orbital Inflammation From Orbital Infectious Disease

PURPOSE

The neutrophil-to-lymphocyte ratio (NLR) is a relatively novel biomarker to distinguish between acute stresses. This study was performed to determine whether the NLR may discern infectious orbital maladies from idiopathic orbital inflammation (IOI).

METHODS

The NLR was calculated by a review of the initial blood draws of adult patients who presented to the emergency department at a single academic medical center. Statistical comparisons were performed to identify the significance of these results.

RESULTS

Ten patients with IOI, 12 patients with necrotizing fasciitis (NF), and 12 patients with orbital cellulitis (OC) presented to the emergency department. The groups were not statistically significantly different in terms of age or gender. The mean NLRs were 3.48 (standard deviation = 1.80), 13.5 (standard deviation = 14.5), and 8.15 (standard deviation = 6.56) for IOI, NF, and OC, respectively. Patients with IOI had statistically significantly lower NLRs than patients with NF ( p = 0.037) and OC ( p = 0.034). However, the NLRs of patients with OC were not statistically significantly different from those of patients with NF ( p = 0.27).

CONCLUSIONS

The NLR appears to distinguish IOI from infectious etiologies, but does not discern between variants of infection. These results should be juxtaposed against appropriate imaging and clinical evaluations, but elevated NLR values may heighten clinicians' concerns for an infectious process and encourage them to initiate appropriate management steps.

Infectious eye disease in the 21st century-an overview

Infectious diseases affecting the eye often cause unilateral or asymmetric visual loss in children and people of working age. This group of conditions includes viral, bacterial, fungal and parasitic diseases, both common and rare presentations which, in aggregate, may account for a significant portion of the global visual burden. Diagnosis is frequently challenging even in specialist centres, and many disease presentations are highly regional. In an age of globalisation, an understanding of the various modes of transmission and the geographic distribution of infections can be instructive to clinicians. The impact of eye infections on global disability is currently not sufficiently captured in global prevalence studies on visual impairment and blindness, which focus on bilateral disease in the over-50s. Moreover, in many cases it is hard to differentiate between infectious and immune-mediated diseases. Since infectious eye diseases can be preventable and frequently affect younger people, we argue that in future prevalence studies they should be considered as a separate category, including estimates of disability-adjusted life years (DALY) as a measure of overall disease burden. Numbers of ocular infections are uniquely affected by outbreaks as well as endemic transmission, and their control frequently relies on collaborative partnerships that go well beyond the remit of ophthalmology, encompassing domains as various as vaccination, antibiotic development, individual healthcare, vector control, mass drug administration, food supplementation, environmental and food hygiene, epidemiological mapping, and many more. Moreover, the anticipated impacts of global warming, conflict, food poverty, urbanisation and environmental degradation are likely to magnify their importance. While remote telemedicine can be a useful aide in the diagnosis of these conditions in resource-poor areas, enhanced global reporting networks and artificial intelligence systems may ultimately be required for disease surveillance and monitoring.

Visual outcomes following orbital decompression for orbital infections

OBJECTIVE

To analyze the visual outcomes and sequelae of endonasal intervention for orbital infections.

INTRODUCTION

Orbital infections pose a serious threat to vision in the pediatric population and can result in complications such as blindness, diplopia, intracranial involvement, and death. [1] Orbital decompression by endonasal intervention is a common treatment to address a variety of orbital infections including orbital cellulitis, orbital abscesses, and subperiosteal abscesses. [2] The outcomes of visual sequelae such as loss or limitation of visual acuity, extraocular movements, and increased intraocular pressure following orbital decompression via endonasal intervention have not been sufficiently investigated in the current literature.

METHODS

This retrospective cohort study was performed at our tertiary care pediatric hospital using data from 69 patients aged 0-18 years who were admitted between 2008 and 2018. Data was extracted from the electronic medical record system.

RESULTS

Following endoscopic sinus surgery, symptoms of orbital infection improved throughout the cohort. Improvement in visual acuity is demonstrated by a statistically significant decrease in the average logMAR value in both the right and left eye (P = 0.002 and P = 0.028 respectively). There was also a significant improvement to normal values postoperatively for patients who initially presented with abnormal tonometry, extraocular movement, and the appearance of eyelids and eyelashes.

CONCLUSION

There is no decline or loss of vision with otolaryngology surgical intervention for orbital cellulitis in our cohort. This retrospective chart review demonstrates the efficacy of surgical intervention on overall visual outcomes following endonasal intervention for orbital infections such as orbital cellulitis, orbital abscesses, and subperiosteal abscesses.

Non-visual complications of orbital cellulitis (NVCOC) in pediatric vs adult populations

PURPOSE

There have been many publications evaluating the visual outcomes of patients treated for orbital cellulitis. The aim of this study was to evaluate non-visual complications of post-septal orbital cellulitis (NVCOC) present 30 days after discharge from index hospitalization.

METHODS

This was an IRB-approved, retrospective chart review.

RESULTS

Ninety patients (45 pediatric, 45 adults) were identified with OC. NVCOC were significantly more common in adult patients as compared to children (40.0% vs 15.6% respectively; p < 0.05). The most common NVCOC among children was persistent ptosis, while clinically significant scarring was most common in adults. NVCOC were less persistent in children as compared to adults with 71.4% of complications in children resolving spontaneously by 6 month follow up as compared to 11.1% adults. (p < 0.05). The only statistically significant risk factor identified for the development of NVCOC in children and adults was the presence of ICE (intracranial extension) during index hospitalization (p < 0.05) and the presence of an infected orbital implant (p < 0.05) respectively.

CONCLUSIONS

Adult patients experience NVCOC complications more often than children. Furthermore, the nonvisual complications in children are more likely to resolve spontaneously than those in adults. The intracranial spread of infection is a significant risk factor for late complications in children. The presence of an orbital wall/floor implant is a significant risk factor for late complications in adults. There are many differences in the etiology, pathophysiology, and course of NVCOC in children and adults, so information on these two populations should be reported separately.

Orbital cellulitis with panophthalmitis and scleral necrosis - a case report

BACKGROUND

Orbital cellulitis is common in young children and is often secondary to coexisting sinus disease. Coexisting orbital cellulitis and panophthalmitis is a rare clinical event and usually occurs secondary to trauma or from an endogenous source.

CASE PRESENTATION

A febrile 2-year-old male presented with periorbital inflammation and exudative retinal detachment. Imaging showed acute sinusitis and extensive orbital cellulitis. Because of progressive scleral thinning, the patient underwent enucleation.

CONCLUSION

We present a case of concurrent orbital cellulitis, panophthalmitis, and scleral necrosis in an immunocompetent pediatric patient. Timely intervention is important to prevent life threatening complications with the rare occurrence of coexistent orbital cellulitis and panophthalmitis.

Serologic Evaluations in the Distinction Between Sinusitis-Related Orbital Cellulitis and Periorbital Necrotizing Fasciitis

PURPOSE

While sinusitis-related orbital cellulitis (SROC) and periorbital necrotizing fasciitis (PNF) share similar clinical presentations, they are managed differently, making rapid recognition of the appropriate clinical entity critical to optimal outcomes. This study was performed to assess whether serologic testing might help clinicians to distinguish between SROC and PNF.

METHODS

A retrospective review analysis was used to compare initial complete blood counts and comprehensive metabolic panels among adult patients with SROC and PNF. Statistical evaluations were used to determine the significance of differences between the groups.

RESULTS

Thirteen patients with PNF and 14 patients with SROC were identified. The 2 groups were similar in age, gender, and likelihood of immunosuppression ( p > 0.05 for each metric). Mean leukocyte counts were 18.52 (standard deviation = 7.02) and 10.31 (standard deviation = 5.77) for PNF and SROC, respectively ( p = 0.0057). White blood cell levels were above normal limits for 12 patients with PNF (92.3%) and 7 patients with SROC (50%) ( p = 0.017). No other laboratory test was significantly different between the 2 groups.

CONCLUSIONS

While the majority of serologic testing was quite similar in patients with either SROC or PNF, leukocyte levels may represent an important clue to distinguish between the two diseases. Clinical evaluation remains the gold standard to make the proper diagnosis, but markedly elevated white blood cell counts should prompt clinicians to at least consider a diagnosis of PNF.

Microbiology and Antibiotic Resistance Profiles of Orbital Subperiosteal Abscesses: A Comparison of Pediatric, Adolescent, and Adult Populations

PURPOSE

The purpose of this study was to compare the microbiology and antibiotic resistance profiles of orbital subperiosteal abscesses (SPA) among 3 age cohorts.

METHODS

A retrospective study was conducted at a tertiary care center through a medical record search to identify patients with orbital cellulitis and SPA on imaging from January 1, 2000 to September 10, 2022. Patients were categorized into pediatric (<9 years old), adolescent (9-18 years old), and adult (>18 years old) cohorts. Primary outcomes included culture and antibiotic susceptibility results. Secondary outcomes included antibiotic therapy and surgical intervention.

RESULTS

Of the 153 SPA patients included, 62 (40.5%) were in the pediatric cohort (4 months-8 years, mean 5.0 ± 2.7), 51 (33.3%) were adolescent (9-18 years, 12.7 ± 2.8), and 40 (26.1%) were adult (19-95, 51.8 ± 19.3). Viridians group Streptococci were the most frequent organisms isolated across groups. The anaerobic infection rate was higher in the adult compared to the pediatric group (23.0% vs, 4.0%, p = 0.017), while that of the adolescent did not differ significantly from either. Pediatric patients carried a lower rate of clindamycin resistance than adolescent and adult cohorts, who shared similar rates (0 vs. 27.0% and 28.0%, respectively; p = 0.016). There were progressive increases in duration of intravenous antibiotic therapy ( p < 0.195) and rate of surgical intervention ( p < 0.001) going from younger to older cohorts.

CONCLUSION

Organisms isolated from orbital SPA from the past 2 decades demonstrate a predominance of Streptococcal species. Older age may be associated with anaerobic infection, clindamycin resistance, and more aggressive management. Adolescent infections are more similar to adult rather than pediatric counterparts but may require less aggressive management than the former.

Impact of Season on Incidence of Sinusitis-related Orbital Cellulitis

PURPOSE

To explore the impact of season on the incidence of presentation to emergency departments with sinusitis-related orbital cellulitis in the United States.

METHODS

The National Emergency Department Sample was queried to identify cases of patients with sinusitis-related orbital cellulitis. Patient's age, location, and the month of presentation were recorded. Statistical correlations were analyzed via a dedicated software package.

RESULTS

A total of 439 patients with sinusitis-related orbital cellulitis were identified. The overall incidence was higher during the winter months ( p < 0.05); while children were more likely to develop this disease during the winter ( p < 0.05), season was not statistically correlated with its incidence among adults ( p = 0.16). The incidence of orbital cellulitis was higher during the winter in the midwest and south regions of the United States ( p < 0.05 for each region), although this correlation did not apply in the northeast and west ( p = 0.60 and 0.99, respectively).

CONCLUSIONS

While sinusitis incidence increases during the winter, the relationship between season and orbital cellulitis is complex and varies by age and geographic location. These findings may help to facilitate screening protocols for this disease and to define staffing issues for emergent ophthalmic care.

A rare ocular complication of septicemia: a case series report and literature review

BACKGROUND

Septicemia that leads to ocular involvement mostly presents as endophthalmitis or panophthalmitis. Contrarily, septicemia without intraocular involvement, known as hematogenous orbital cellulitis (HOC), involves only the orbit and is an extremely rare complication of septicemia and a rare type of orbital cellulitis.

CASE PRESENTATION

Four male patients with septicemia presented with orbital involvement without intraocular infection were described in this study. They were 22 (case 1), 15 (case 2), 79 (case 3), and 30 (case 4) years old, with a mean age of 29.75 years. All patients were immunocompromised except for case 2. Cases 1 and 3 had a history of steroid use, whereas case 4 was in a post-chemotherapy myelosuppression phase. Septicemia in case 1 was community-acquired, cases 3 and 4 were hospital-acquired, and case 2 was secondary to acne squeezing. Blood cultures from cases 1, 2, and 3 were positive for Candida albicans, methicillin-resistant Staphylococcus aureus, and Klebsiella pneumoniae, respectively. Case 4 had negative cultures; however, next-generation sequencing reported the presence of Enterococcus faecalis and Rhizopus oryzae. Case 1 had right eye involvement, and both eyes were involved in the other three cases. According to Chandler's classification, case 1 was type 2, case 2 was type 2 (OD) and type 4 (OS), and cases 3 and 4 were type 1 orbital infections. All patients had eyelids erythema, and cases 1 and 2 had mildly decreased visual acuity, proptosis, and painful and restricted ocular motility. Hospital stays ranged from 13 to 43 days (mean, 24 days). All patients received systemic antibiotic therapy based on drug sensitivity and next-generation sequencing results, in combination with multidisciplinary treatment, resulting in complete recovery of ocular and systemic signs and symptoms; no ocular surgical interventions were performed. Extraocular muscle palsy was the last symptom to resolve.

CONCLUSION

HOC is predominantly seen in immunocompromised individuals with a high proportion of hospital-acquired infections and positive cultures for pathogens. Infection control using systemic antibiotics targeted at the causative organism guarantees a favorable prognosis.

Microbial patterns and culture utility in orbital cellulitis

PURPOSE

To determine the prevalence and types of pathogens found in children with orbital cellulitis and to evaluate the utility of nonoperative cultures.

METHODS

This was a retrospective cohort study of children with imaging-confirmed orbital cellulitis over a period of 8 years. Outcomes included prevalence and types of organisms, polymicrobial infection, mixed aerobic-anaerobic infection, effect of age, and culture utility.

RESULTS

Of 220 children with orbital cellulitis, 112 (51%) had cultures taken; 69 (31%) had surgical intervention. Culture sources for the 112 children with cultures included blood (57 patients [51%]), sinus (53 [47%]), orbit (42 [38%]), brain (6 [5%]), and skin/conjunctiva/lacrimal sac (6 [5%]). Streptococcus anginosus group strains grew in cultures from 19 children (17%); methicillin-sensitive Staphylococcus aureus (MSSA), in 15 (13%); Streptococcus pyogenes, in 12 (11%); methicillin-resistant Staphylococcus aureus (MRSA), in 6 (5%); anaerobic/facultative gram negative rods, in 8 (7%); anaerobic Gram-positive cocci, other Viridans group streptococci, and Streptococci pneumoniae, in 3 (3%) each; and normal respiratory/skin flora, in 23 (21%). Polymicrobial infection (P = 0.08) and anaerobic organisms (P = 0.58) did not differ by age (range, 0.1-16.8 years). In all 220 (100%) children, nonoperative cultures were either not obtained (108 [49%]), not helpful in avoiding surgery (69 [31%]), showed no growth (39 [18%]), or grew an organism that did not change management from empiric therapy (4 [2%]).

CONCLUSIONS

While many organisms may be cultured from children with orbital cellulitis, Streptococcus and MSSA were the most common in our study cohort. MRSA is uncommon, so initial empiric coverage is not necessary. Rates of polymicrobial and anaerobic infection were similar across ages. Our results indicate that nonoperative cultures are not indicated in the initial medical management of orbital cellulitis; in our cohort, they neither resulted in treatment changes nor helped avoid surgery.

Central Retinal Artery Occlusion Due to Subperiosteal Orbital Abscess Caused by Acute Sinusitis in a Child: A Case Report

Central retinal artery occlusion (CRAO) is an ophthalmic emergency and has poor visual prognosis. It is commonly found in elderly people and very rare in child. We reported an 8-year-old girl who suffered from acute sinusitis, periorbital swelling, and the visual acuity of her right eye was only light perception. She was diagnosed with CRAO, SPOA (subperiosteal orbital abscess), and acute sinusitis. Emergency treatments including surgery, antibiotics, glucocorticoids, intraocular-pressure-lowering drugs, and vasodilators were taken immediately in order to save the eyesight. The visual acuity of the right eye returned to 20/400. Conclusions: Severe intraorbital complications of acute sinusitis can lead to CRAO. Timely drainage, strong antibiotics, and glucocorticoids are the most effective methods for the treatments.

A Fatal Rhizopus Species Infection after Facial Injury in a Patient with Myelodysplastic Syndrome and Diabetes Mellitus

A 73-year-old woman with myelodysplastic syndrome and diabetes mellitus, chronic renal failure and paroxysmal atrial fibrillation, received a diagnosis of facial cellulitis and was treated by antibiotics. However, her symptoms deteriorated. Facial magnetic resonance imaging (MRI) showed orbital cellulitis. She had weakness of visual acuity requiring changing the antibiotics. She also underwent steroid pulse treatment. Her symptoms temporarily improved, but she became comatose and died. Results of a molecular analysis of the residual cerebrospinal fluid indicated Rhizopus species infection. For immunocompromised hosts with refractory orbital cellulitis, mucormycosis should be considered as a differential diagnosis, and appropriate treatment should be promptly performed.

Methicillin-resistant Staphylococcus aureus-associated orbital cellulitis: a case series

PURPOSE

In recent years, methicillin-resistant Staphylococcus aureus (MRSA) orbital cellulitis (OC) has drawn increasing clinical and public health concern. We present a case series of MRSA OC encountered at four Australian tertiary institutions.

METHODS

A multi-centre retrospective case series investigating MRSA OC in Australia from 2013 to 2022. Patients of all ages were included.

RESULTS

Nine cases of culture-positive non-multi-resistant MRSA (nmMRSA) OC were identified at four tertiary institutions across Australia (7 male, 2 female). Mean age was 17.1 ± 16.7 years (range 13-days to 53-years), of which one was 13 days old, and all were immunocompetent. Eight (88.9%) patients had paranasal sinus disease, and seven (77.8%) had a subperiosteal abscess. Four (44.4%) had intracranial extension, including one (11.1%) case which was also complicated by superior sagittal sinus thrombosis. Empirical antibiotics, such as intravenous (IV) cefotaxime alone or IV ceftriaxone and flucloxacillin, were commenced. Following identification of nmMRSA, targeted therapy consisting of vancomycin and/or clindamycin was added. Nine (100%) patients underwent surgical intervention. Average hospital admission was 13.7 ± 6.9 days (range 3-25 days), with two patients requiring intensive care unit (ICU) admission due to complications related to their orbital infection. All patients had favourable prognosis, with preserved visual acuity and extraocular movements, following an average follow-up period of 4.6 months (range 2-9 months).

CONCLUSION

NMMRSA OC can follow an aggressive clinical course causing severe orbital and intracranial complications across a wide demographic. However, early recognition, initiation of targeted antibiotics and surgical intervention when required can effectively manage these complications and achieve favourable visual outcomes.

Seasonal variations, acute rhinosinusitis and orbital infections in children

BACKGROUND

Orbital infections in children are commonly secondary to acute bacterial rhinosinusitis (ABRS). It is unclear whether seasonal variations can predispose to these complications mirroring acute rhinosinusitis incidence.

OBJECTIVE

To determine the incidence of ABRS as a cause of orbital infections and whether seasonality is a risk factor.

METHODS

A retrospective review of all children who presented to West Virginia University children's hospital between 2012 and 2022 were reviewed. All children with CT evidence of orbital infection were included. Date of occurrence, age, gender, and presence of sinusitis were reviewed. Children with orbital infection secondary to tumors, trauma, or surgery were excluded.

RESULTS

118 patients were identified with mean age of 7.3 years with 65 (55.1 %) males. 66 (55.9 %) children had concomitant sinusitis on CT scan, and the distribution of orbital complications per season showed 37 (31.4 %) cases occurred in the winter season, followed by 42 (35.6 %) cases in spring, 24 (20.3 %) cases in summer, and 15 (12.7 %) in fall. Children with orbital infections during winter & spring had sinusitis in 62 % of children vs. 33 % in other seasons (P = 0.02). Preseptal cellulitis was present in 79 (67 %) children, 39 (33 %) children with orbital cellulitis, and 40 (33.9 %) children with abscesses. 77.6 % children were treated with IV antibiotics and 94 % with oral antibiotics, and 14 (11.9 %) with systemic steroids. Only 18 (15.3 %) children required surgery.

CONCLUSIONS

There seems to be a seasonal predisposition for orbital complications mainly in the winter and spring seasons. Rhinosinusitis was present in 55.6 % of children presenting with orbital infections.

LEVEL OF EVIDENCE: 4

Fatal Orbital Cellulitis With Intracranial Abscess: A Case Report

Orbital cellulitis is a sight- and life-threatening condition. Prompt diagnosis and immediate intervention are required. We report a case of fatal odontogenic orbital cellulitis complicated with intracranial abscesses in a 55-year-old gentleman. The patient presented with painful swelling of the left eye associated with reduced eye movement, blurry vision, and a headache. There was generalized periodontitis. Initial imaging was suggestive of left eye orbital cellulitis with intracranial abscess, and intensive systemic antibiotic therapy was initiated. After six weeks of antibiotic therapy, there was an improvement in ocular signs and symptoms. However, the patient developed signs of meningism with a persistent fever. Serial brain imaging demonstrated worsening intracranial abscesses. The patient died eight weeks after the initial onset of presentation. This case emphasized that brain abscesses could be a fatal complication of odontogenic orbital cellulitis. A high index of suspicion is important in diagnosing orbital cellulitis and its complications. Early consideration of surgical intervention is necessary in cases not responding to antibiotic therapy.

Fusobacterium necrophorum Orbital Cellulitis With Intraconal Abscess

A 19-year-old male presented to the emergency department with progressive right eye proptosis and was subsequently diagnosed with bacterial orbital cellulitis and acute on chronic allergic fungal sinusitis. He experienced brief symptomatic improvement after endoscopic sinus surgery, initiation of antibiotics, and steroid treatment; however, he re-presented five days after discharge with significantly worsened symptoms and no light perception in the right eye. Cultures resulted in Aspergillus and Fusobacterium necrophorum, a rare, aggressive etiology of bacterial orbital cellulitis. He developed an intraconal abscess requiring multiple orbitotomies for decompression and abscess drainage. To our knowledge, only eight prior cases of F. necrophorum orbital cellulitis have been reported in the literature (excluding the present case) and our patient is the first case of this organism causing an intraconal abscess. The authors discuss the importance of early recognition and close follow-up of F. necrophorum orbital infections.

Monocular Vision Loss in a Patient With Earache and Night Sweats

A 62-year-old patient with a history of painless vision loss in her right eye, right ear pain and fullness, discomfort over her frontal and maxillary sinuses, nasal congestion without discharge, drenching night sweats, cramps in her quadriceps, and weight loss presented to the ophthalmology department. Examination revealed normal tympanic membranes and a dry but otherwise normal nasal mucosa on flexible endoscopy. What would you do next?

Differences in characteristics, aetiologies, isolated pathogens, and the efficacy of antibiotics in adult patients with preseptal cellulitis and orbital cellulitis between 2000-2009 and 2010-2019

BACKGROUND/AIMS

To understand whether the epidemiology, aetiologies, common pathogens and the antibiotic efficacy against the identified bacteria of periorbital cellulitis in adults have changed recently (2010-2019) compared with the past decade (2000-2009).

METHODS

Adult patients (n=224) diagnosed with preseptal cellulitis and orbital cellulitis admitted to Kaohsiung Veterans General Hospital during 2000-2019 were retrospectively reviewed. Demographic and clinical characteristics, isolated pathogens and antibiotic susceptibility tests against the commonly cultured bacteria were analysed.

RESULTS

Preseptal cellulitis showed a tendency of female predominance. Patients in their 60s showed an incidence peak; more cases were observed during winter. The most common predisposing factor was dacryocystitis (15.5%-30.5%), followed by hordeolum (15.5%-24.8%). Aetiology of sinusitis (p=0.001) decreased and that of conjunctivitis (p=0.007) increased significantly with time. Culture results of nasopharyngeal swabs and local abscess showed higher positivity rate than conjunctival swab. The most common isolates were methicillin-susceptible Staphylococcus aureus, methicillin-resistant S. aureus, coagulase-negative staphylococci and Pseudomonas aeruginosa. Antibiotics including fluoroquinolones and vancomycin were effective; in contrast, ampicillin/sulbactam and oxacillin showed decreasing efficacy against gram-positive bacteria. For antibiotic treatment against P. aeruginosa, fluoroquinolones, ceftazidime, piperacillin and imipenem were ideal choices.

CONCLUSION

In isolated pathogens, the increasing trend of methicillin-resistant S. aureus detection was compatible with reducing oxacillin efficacy against periorbital infection. In our study, the report of antibiotic efficacy against the most common identified bacteria offered empirical choices for hospitalised patients with periorbital infection before obtaining culture results.

High risk and low prevalence diseases: Orbital cellulitis

INTRODUCTION

Orbital cellulitis is an uncommon but serious condition that carries with it a potential for significant morbidity.

OBJECTIVE

This review highlights the pearls and pitfalls of orbital cellulitis, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Orbital cellulitis refers to infection of the globe and surrounding soft tissues posterior to the orbital septum. Orbital cellulitis is typically caused by local spread from sinusitis but can also be caused by local trauma or dental infection. It is more common in pediatric patients compared to adults. Emergency clinicians should first assess for and manage other critical, sight-threatening complications such as orbital compartment syndrome (OCS). Following this assessment, a focused eye examination is necessary. Though orbital cellulitis is primarily a clinical diagnosis, computed tomography (CT) of the brain and orbits with and without contrast is critical for evaluation of complications such as abscess or intracranial extension. Magnetic resonance imaging (MRI) of the brain and orbits with and without contrast should be performed in cases of suspected orbital cellulitis in which CT is non-diagnostic. While point-of-care ultrasound (POCUS) may be useful in differentiating preseptal from orbital cellulitis, it cannot exclude intracranial extension of infection. Management includes early administration of broad-spectrum antibiotics and ophthalmology consultation. The use of steroids is controversial. In cases of intracranial extension of infection (e.g., cavernous sinus thrombosis, abscess, or meningitis), neurosurgery should be consulted.

CONCLUSION

An understanding of orbital cellulitis can assist emergency clinicians in diagnosing and managing this sight-threatening infectious process.

Microbiology of bacterial orbital cellulitis-tertiary institutional experiences in South Australia: a multi-centre retrospective study

PURPOSE

This study describes the microbiology of bacterial orbital cellulitis (OC) over an 11-year period and its clinical associations at three tertiary institutions in Adelaide, South Australia.

METHODS

Multi-centre retrospective study of the microbiology of bacterial OC between January 2012 and August 2022. Pre-septal cellulitis was excluded. Differences in means were determined by the Independent Samples t-test, and categorical data was analysed via Pearson's Chi square. A P-value < 0.05 was statistically significant.

RESULTS

99 patients (male: 69, mean age: 22.0 ± 23.8 years old), of which 70.7% were aged ≤ 18 years. Sinus and orbital abscess cultures had the greatest positive yield (73.7%). Frequency of organisms: Streptococcus species (34.3%), Staphylococcus aureus (28.3%), Haemophilus species (5.1%), mixed anaerobes (3.0%), Enterobacter cloacae (2.0%), Moraxella catarrhalis (1.0%), Pseudomonas aeruginosa (1.0%), Corynebacterium species (1.0%), Klebsiella pneumoniae (1.0%), Proteus mirabilis (1.0%), Citrobacter koseri (1.0%), and Enterococcus species (1.0%). Streptococcus species predominated in the paediatric population, with a statistically significant difference in mean age between Streptococcus species and Staphylococcus aureus (14.1 ± 16.5 vs 27.6 ± 24.6 years old, respectively) (P = 0.028). No organism was cultured in 32.3% of cases. Methicillin-resistant Staphylococcus aureus (MRSA) accounted for 28.6% of all Staphylococcus aureus isolates, with 50% occurring between 2021 and 2022.

CONCLUSION

Yearly microbiological trends have remained largely constant in South Australia. The causative organism was not identified in 32.3% of cases, further emphasising appropriate empirical antibiotics, and obtaining microbiology from various sources. MRSA OC remains of increased clinical and public health concern and may be associated with a more aggressive disease course.

Rare Case of Bilateral Orbital Cellulitis in an Adult, Caused by Enterococcus faecalis

Orbital cellulitis is a serious, life-threatening infection, typically in paediatric patients, and its bilateral presentation in adults is atypic. We present an unusual bilateral manifestation of orbital cellulitis and abscess, caused by Enterococci in an adult patient. E. faecalis is an extremely rare cause of orbital inflammation and we found three published case reports only, all of which are unilateral and seen in children. A 51-year-old male presented with 1-week history of pyrexia, painful proptosis, periorbital swelling, and low vision of both eyes. He was diagnosed with bilateral orbital cellulitis and was treated with empiric antibiotic medication for 8 days, but symptoms persisted. MRI showed bilateral intra- and extraconal fluid-intensity collections. Microbiology was taken from the orbit and revealed Enterococcus faecalis invasion. Pus collections were drained for 1 week. Systemic and intraorbital antibiotics were administered. The patient recovered and vision returned to normal. This is a rare case of bilateral orbital cellulitis and abscesses with invasive E. faecalis infection. E. faecalis infection of the orbit is unusual and should be considered, especially if patient does not respond to empiric antibiotic therapies.

Surgical Approaches in Odontogenic Orbital Cellulitis (OOC): Our Experience and Review of Literature

Aims Odontogenic orbital cellulitis represents a complication of root infections of upper pre-molars and molars. The severity depends on the orbital structure involved. The treatment is based on antibiotic therapy associated or not to surgery. Through the presentation of three cases and a review of literature, we purpose as aim of our study to underline the necessity of a timely diagnosis and to provide the correct surgical approach in each different types and stages of orbital infections. Methods We present three patients that were affected by dental infection evolved in orbital cellulitis. In two cases the disease was solved with the extraction of infected tooth and a surgical endoscopic drainage of the abscess through antrostomy of maxillary sinus. In the third patient the disease had already induced a bulbar perforation and endophthalmitis, so an orbit evisceration was necessary. Results Review of literature showed that the standard treatment of orbital cellulitis is the transnasal approach associated or not by a transoral and/or transcutaneous procedure depending on the stage of the disease and on the causes. In our 3 cases these indications were followed without relapses of the disease. Conclusion An early diagnosis is mandatory in odontogenic orbital cellulitis specially to avoid serious complications. Surgical treatment can be simple and effective mostly in early-stage infection: it is based on extraction of infected tooth and on the drainage of abscess. Surgical approach consists in transnasal procedure flanked or not by transoral and transcutaneous procedures based on the stage of the infection considering involved structures.

The Nasopharyngeal Carcinoma and Its Effect on the Infectious Eye Disease: A Nationwide Cohort Study

The purpose of this study is to investigate the potential correlation between nasopharyngeal carcinoma (NPC) and both infectious keratitis and orbital cellulitis. The retrospective cohort study used the National Health Insurance Research Database (NHIRD) as a data source. A total number of 4184 patients with NPC diagnosis were selected and matched to 16,736 non-NPC patients via the propensity-score matching (PSM). The main outcomes are the development of infectious keratitis and orbital cellulitis according to diagnostic codes and related medications. The Cox proportional hazard regression was adopted to estimate the adjusted hazard ratio (aHR) and 95% confidence interval (CI) of outcomes between the two groups. A total of 35 and 19 episodes of orbital cellulitis occurred in the NPC and non-NPC groups and the aHR was significantly higher in the NPC group (aHR: 1.34, 95% CI: 1.23−1.46, p = 0.0024). There were 2185 and 659 events of infectious keratitis in the NPC and non-NPC groups, and the NPC group revealed a significantly higher aHR than non-NPC group (aHR: 1.34, 95% CI: 1.23−1.46, p < 0.0001). Besides, the cumulative probability of infectious keratitis was significantly higher in the NPC group than the non-NPC group (p < 0.0001). The other risk factors of infectious keratitis include age from 20 to 30 years old, allergic respiratory diseases, allergic dermatological diseases, and external eye diseases (all p < 0.0001). In subgroup analyses, both the incidences of infectious keratitis (aHR: 1.33, 95% CI: 1.21−1.47) and orbital cellulitis (aHR: 2.36, 95% CI: 1.27−4.39) were significantly higher than the non-NPC group. The incidence of infectious keratitis was significantly higher in NPC patients without radiotherapy (aHR: 1.40, 95% CI: 1.26−1.55) compared to non-NPC population, while the rate of orbital cellulitis was similar between the NPC patients without radiotherapy (aHR: 0.76, 95% CI: 0.27−2.14) and non-NPC population. In conclusion, the existence of NPC associates with higher incidence of infectious keratitis which increases with NPC period, and the radiotherapy may be account for the higher rate of orbital cellulitis in NPC population.

A Rare Fungal Orbital Infection in an Immunocompetent Young Male Caused by Lichtheimia corymbifera (Absidia corymbifera)

AIM

To present a case of orbital fungal infection caused by a rare fungus, Lichtheimia corymbifera (Absidia corymbifera) in an immunocompetent individual.

MATERIALS AND METHODS

A retrospective case study.

RESULT

A 23-year-old male presented with painful proptosis of the right eye for 3 months. Examination revealed normal vision and pupillary light reflex but restricted ocular movements in the right eye. A tender, firm mass was palpable along the inferomedial quadrant of the right orbit. He had acute worsening of proptosis with loss of light perception within 24 hours. Magnetic resonance imaging (MRI) showed a heterogeneously enhancing lesion in the right orbit. Urgent incisional biopsy revealed the growth of Absidial fungal infection. He received intravenous Amphotericin B for 2 weeks with no response. Repeat MRI revealed an extension of the infection up to the cavernous sinus and intracranial optic nerve. He was managed by subtotal exenteration, socket irrigation with Amphotericin B, and intravenous Amphotericin B.

CONCLUSION

Invasive orbital fungal infection, though rare, should be considered a differential diagnosis in immunocompetent patients with fulminant proptosis and vision loss.

Magnetic Resonance Imaging of Head and Neck Emergencies, a Symptom-Based Review, Part 1: General Considerations, Vision Loss, and Eye Pain

Use of magnetic resonance (MR) imaging in the emergency department continues to increase. Although computed tomography is the first-line imaging modality for most head and neck emergencies, MR is superior in some situations and imparts no ionizing radiation. This article provides a symptom-based approach to nontraumatic head and neck pathologic conditions most relevant to emergency head and neck MR imaging, emphasizing relevant anatomy, "do not miss" findings affecting clinical management, and features that may aid differentiation from potential mimics. Essential MR sequences and strategies for obtaining high-quality images when faced with patient motion and other technical challenges are also discussed.

Focus on Ophthalmopathology - Orbital Infections from Hordeolum to Necrotizing Fasciitis

(Peri)orbital infections comprise a multitude of diagnoses, ranging from common hordeolum to rare but life-threatening necrotizing fasciitis. However, these disease entities are rarely diagnosed by an ophthalmic pathologist because (peri)orbital infections are usually diagnosed clinically, with the help of imaging and microbiological techniques when indicated. In this review article, the role of ophthalmopathology in the diagnosis of (peri)orbital infections is illustrated on the basis of several exemple diagnoses. An infectious hordeolum must be distinguished from a noninfectious chalazion. A nodular thickening of the eyelid, which is diagnosed and treated as a chalazion, can hide a malignant neoplasia. The correct diagnosis and treatment of canaliculitis is often delayed. In this context the most common causative organism, Actinomyces, can be depicted histologically, as can lacrimal stones/dacryoliths. Necrotizing fasciitis is a rapidly worsening infection of the fascia, which can lead to necrosis, sepsis, and death. During the Sars-CoV2 pandemic, an increased incidence of mucormycosis cases was observed, especially in India. This superinfection was facilitated by the widespread use of steroids and immunosuppression. Histologically, it is possible to visualize infiltration of vessel walls by the fungus. Ophthalmopathology contributes to the diagnosis and to understanding the pathophysiology of these diseases.

Management of intraorbital infections in the pediatric emergency department

Intraorbital infections may lead to severe complications, necessitating rapid diagnosis and intervention. The decision process regarding the need for emergent imaging and possible surgical intervention is unclear in the literature. This retrospective cohort study included two major pediatric emergency departments in Israel between 2010 and 2020. Patients arriving at the emergency department with an admission diagnosis of intraorbital infection and at least one high-risk symptom for orbital involvement were included in the study. The main outcome measures were the computerized tomography (CT) timing and results, whether the case was managed surgically or conservatively and whether the patient returned to the same hospital with significant complications. Ninety-five patients were included; 70 underwent a CT scan in the first 24 h, and of those 21 were managed surgically; 16 were treated based on clinical findings alone, with no imaging performed. When comparing groups based on management, we found no significant differences based on presenting symptoms, duration of complaints, or severity of CT findings. However, having three or more high-risk presenting symptoms was associated with a greater likelihood of surgical intervention (multivariate logistic regression p = 0.069, odds ratio 1.73, 95% confidence interval 0.96-3.11; one-way ANOVA and Fisher's exact test p < 0.05).

CONCLUSION

The decision to treat intraorbital infections at our institutions appears to be based on clinical impression of disease severity rather than radiologic findings. This suggests a need for further interdisciplinary studies to clarify optimal management.

WHAT IS KNOWN

• Orbital c ellulitis is associated with significant potential complications, necessitating rapid diagnosis and treatment. • Present literature provides insufficiently clear guidance on emergency department management.

WHAT IS NEW

• Consideration of all relevant factors (clinical features, laboratory findings, timing of imaging, and conservative vs. surgical management) in a single retrospective cohort. • Our findings suggest that decision-making in practice may be guided by clinical impression rather than imaging.

Extraocular muscle enlargement

Extraocular muscle enlargement can occur secondary to a range of orbital and systemic diseases. Although the most common cause of extraocular muscle enlargement is thyroid eye disease, a range of other inflammatory, infective, neoplastic, and vascular conditions can alter the size and shape of the extraocular muscles. Imaging with computed tomography and magnetic resonance imaging plays an essential role in the workup of these conditions. This article provides an image-rich review of the wide range of pathology that can cause enlargement of the extraocular muscles.

Clinical Characteristics and Risk Factors for Evisceration in Trauma-Dominant Orbital Cellulitis: A 10-Year Review

Purpose

To analyze the clinical characteristics of trauma-dominant orbital cellulitis (OC) and evaluate the risk factors associated with evisceration.

Methods

This retrospective study included inpatients diagnosed with orbital cellulitis at the Zhongshan Ophthalmic Center between January 2010 and December 2020. The demographic features, etiology, clinical characteristics, microbiological isolates, and risk factors associated with evisceration were analyzed.

Results

Among 148 consecutive subjects (n = 148, 148 eyes), the mean age was 42.07 ± 20.35 years and 70.27% were male. Penetrating globe injuries were the most common (52.03%). No light perception (NLP) was recorded in 50% of patients on admission. Endophthalmitis was observed in 103 cases (69.59%), intraocular foreign bodies (IOFB) were detected in 43 cases (29.05%), and total corneal melting was observed in 31 cases (20.95%). Sixty patients (40.54%) underwent evisceration. Logistic regression analysis showed that total corneal dissolution [odds ratio (OR) = 83.019, P = 0.000], IOFB (OR = 3.402, P = 0.016), and NLP (OR = 0.185, P = 0.001) were risk factors for evisceration. Microorganism detection showed that Pseudomonas aeruginosa and Bacillus cereus were the leading pathogens.

Conclusion

Among hospitalized trauma-dominant OC patients, middle-aged men were the major subjects and penetrating globe injury was the major cause. Significant complications such as complete visual loss and evisceration were unavoidable in many patients with OC in the current study. NLP, IOFB, and total corneal melting were the risk factors for evisceration.

Optic Perineuritis Associated With Cryptococcal Meningitis Presenting With a "Hot Orbit" in a Patient With Chronic Lymphocytic Leukemia

ABSTRACT

A 75-year-old man presented with 3 days of progressive left retro-orbital pain, eyelid swelling, tearing, and pain with extraocular movement. His medical history was significant for type II diabetes mellitus and chronic lymphocytic leukemia, stable on no therapy since diagnosis 8 years prior. The initial examination was significant for diffuse restriction of left ocular motility, marked lid edema, and mild dyschromatopsia. Computed tomography demonstrated asymmetric left periorbital soft tissue swelling and intraconal fat stranding with an irregular left optic nerve sheath complex and clear paranasal sinuses. He was hospitalized for orbital cellulitis and treated empirically with broad-spectrum intravenous antibiotics, but his visual acuity declined over the ensuing 2 days. Subsequent MRI demonstrated left-greater-than-right circumferential optic nerve sheath enhancement, and leptomeningeal enhancement. An orbital biopsy demonstrated monoclonal B-cell lymphocyte aggregation, whereas a lumbar puncture was positive for Cryptococcus antigen with subsequent demonstration of abundant Cryptococcus by Papanicolaou stain. The final diagnosis was optic perineuritis secondary to cryptococcal meningitis presenting with orbital inflammation. Although his clinical course was complicated by immune reconstitution inflammatory syndrome, symptoms and signs of optic neuropathy ultimately resolved after 1 month of intensive antifungal therapy.

Case Report: Corneal perforation secondary to orbital cellulitis caused by Streptococcus pseudoporcinus infection

INTRODUCTION

This report described a rare case of corneal perforation secondary to orbital cellulitis caused by Streptococcus pseudoporcinus (S. pseudoporcinus) infection. To the best of our knowledge, only six cases of S. pseudoporcinus infection have been reported. This case report suggested that S. pseudoporcinus infection was contagious and potentially life threatening. The report emphasized the value of managing infections early to avoid serious consequences.

CASE DESCRIPTION

A patient with orbital cellulitis, which progressed to corneal perforation was admitted to the hospital for right facial swelling, pain, and decreased vision in his right eye. S. pseudoporcinus infection was found after bacterial culture of pus puncture. After aggressive anti-infection and surgical treatment, the infection was eliminated, and the patient was discharged. However, the patient had sustained permanent vision loss.

CONCLUSIONS

This case suggested the potential risk of corneal perforation and orbital cellulitis caused by S. pseudoporcinus infection in humans. The specific biological changes and mode of action of S. pseudoporcinus are unclear and need further investigation.

Orbital abscess: 20 years' experience at a tertiary eye care center

PURPOSE

To study the clinical, microbiological profile and management outcomes of orbital abscess at a tertiary care center in South India.

MATERIAL AND METHOD

In a retrospective interventional case series, we reviewed all patients diagnosed with orbital cellulitis from 2000-2020. The data analyzed included demographic profile, clinical and radiological features, microbiological profile, and management outcome.

RESULTS

A total of 921 cases of orbital and periorbital infections were reviewed. Seventy-two cases were diagnosed as orbital cellulitis. Thirty-four cases (47.22%) had radiological evidence of orbital abscess. The median age was 20.63 years. Three patients (8.82%) were neonates. A male preponderance was noted (23, 67.65%). Sinusitis (10, 29.41%) and diabetes (5, 14.7%), were the most common predisposing factors. Optic neuropathy was seen in 15 (44.11%) patients, cavernous sinus thrombosis in two patients (5.88%), and septicemia in one patient (2.94%) Multiple orbital abscesses were noted in 7 (20.59%) cases. All patients underwent surgical drainage. Methicillin-sensitive Staphylococcus aureus was the most common organism isolated in 14 patients (41.18%). Vision improvement or stabilization was seen in all except 3 (8.82%).

CONCLUSION

Orbital abscess is a potential sight-threatening orbital infection. The infective process can spread and ascend up to involve cavernous sinus thereby becoming life-threatening. A timely diagnosis and intervention can halt the disease process and help restore vision in many cases.

Critical infections in the head and neck: A pictorial review of acute presentations and complications

Non-traumatic head and neck emergencies include several disease processes such as infectious, inflammatory, and malignant. Infections are among the most common pathological processes that affect the head and neck, and are particularly important due to their acute, severe, and potentially life-threatening nature. Radiologists need to be well acquainted with these entities because any delay or misdiagnosis can lead to significant morbidity and mortality. Having a general understanding of such diseases is crucial, their prevalence, clinical presentation, common causative pathogens, route of spread, potential complications, and multimodality radiological appearance. Furthermore, understanding the relevant anatomy of the region, including the various fascial planes and spaces, is essential for radiologists for accurate image interpretation and assessment of potential complications. Our aim is to review the most common severe infections affecting the head and neck as well as other rare but potentially life-threatening infections. We will also describe their imaging features while focusing on the anatomy of the regions involved and describing their potential complications and treatment options.

Fungi of the human eye: Culture to mycobiome

The focus of the current review is multi-fold and compares the diversity and abundance of fungi on the ocular surface by the conventional culture-based method with the more sensitive, high throughput, culture-independent NGS method. The aim is to highlight the existence of a core ocular mycobiome and explore the transition of the ocular fungal microbiota from the normal eye to the diseased eye. PubMed, Google Scholar and Medline were used to search for publications and reviews related to cultivable fungi and the mycobiome of the normal and diseased eye. The conventional cultivable approach and the NGS approach confirm that the eye has its own mycobiome and several confounding factors (age, gender, ethnicity etc.) influence the mycobiome. Further, dysbiosis in the mycobiome appears to be associated with ocular diseases and thus impacts the health of the human eye. Considering that the mycobiome of the eye is influenced by several confounding factors and also varies with respect to the disease status of the eye there is a need to extensively explore the mycobiome under different physiological conditions, different ethnicities, geographical regions etc. Such studies would unravel the diversity and abundance of the mycobiomes and contribute to our understanding of ocular health. Research focused on ocular mycobiomes may eventually help to build a targeted and individualized treatment.

Pediatric orbital cellulitis: Case report of an unusual etiology and pathogen

Orbital cellulitis is an uncommon condition with risks to sight and life. As a complication of maxillofacial injuries, the literature suggests this is only possible with fractures or direct inoculation, and there are no reports to the contrary. Here, we make the first report of a possible etiology by which orbital cellulitis developed in a 14-year-old boy even without skin breach or bony fractures; as well as a rare causative pathogen. He presented with facial abscess and progressive orbital cellulitis after blunt facial trauma, requiring functional endoscopic sinus surgery with needle aspiration of facial abscess externally. Cultures showed growth of Streptococcus constellatus/Parvimonas micra, and he received further antibiotics with full recovery.The pathophysiology of orbital cellulitis in this patient is attributed to vascular congestion and local pressure from maxillofacial contusion and maxillary hemoantrum, with impaired paranasal sinus ventilation encouraging anaerobic bacterial growth. Further progression led to facial abscess formation and intraorbital spread with orbital cellulitis. The pediatric demographic is injury-prone, and self-reporting of symptoms can be delayed. Hence, increased suspicion of complicated injuries and orbital cellulitis may be required when managing maxillofacial contusions so that prompt treatment can be given.

Resolution of refractory orbital cellulitis in an immunocompetent child: A case report

Introduction

Orbital cellulitis in children is a potentially fatal emergency and develops rapidly, leading to severe visual loss and life-threatening complications.

Presentation of case

We report a case of a 16-month-old girl who presented to the emergency department unconscious with a four-day history of a swollen right eyelid. CT scan revealed soft tissue swelling at the superior and inferior palpebral region with bilateral maxillary sinusitis. She had a severe sepsis and received intravenous antibiotics. After her general condition improved, she underwent surgical drainage in conjunction with mini-FESS (functional endoscopic sinus surgery)-the culture of purulent material from which Staphylococcus Aureus was isolated. After a few days, she had hospital-acquired pneumonia, and an abscess in her right eyelid reformed. Immunoglobulin test and lymphocyte subset test was normal. The patient underwent re-surgical drainage and had complete resolution of refractory orbital cellulitis.

Discussion

Severe refractory orbital cellulitis secondary to indolent infection is oftentimes found in immunocompromised patients or in those with underlying ocular diseases; our immunocompetent patient had a seemingly mild case of sinusitis which quickly progressed to severe orbital cellulitis. Oftentimes, broad-spectrum antibiotics are sufficient to treat orbital cellulitis, however, the same cannot be said for our patient, abscess reformed despite appropriate definitive antibiotic therapy in accordance with the culture results.

Conclusion

While the main treatment of orbital cellulitis is administration of antibiotics, in certain conditions as found in our patient, patients may not respond well to conservative treatment. Thus, close monitoring is essential, and any sign of progression warrants prompt surgical drainage.

•

Severe orbital cellulitis from mild sinusitis can occur despite immunocompetence.

•

Unresponsiveness to definitive culture-based antibiotic treatment before surgery

•

Prompt surgical drainage must be considered if patient shows signs of progression.

•

Nosocomial infection and sepsis may complicate orbital cellulitis.

Microbiological profile and antibiotic susceptibility trends in orbital cellulitis in India: an analysis over 15 years

PURPOSE

To report the microbiologic profile and antibiotic susceptibility trends in orbital cellulitis.

METHODS

Retrospective review of microbiology records of orbital cellulitis between 2005 and 2019. Orbital pus or conjunctival swab underwent culture for bacteria and fungi and antibiotic susceptibility testing for bacterial isolates. The microbiological profile and trends in antibiotic susceptibility were analyzed over the three study periods: 2005-2009, 2010-2014, and 2015-2019.

RESULTS

Of the 203 patient samples, 189 (93%) were orbital pus samples, and 146 (72%) were culture positive. Organisms included bacteria (167/203, 82.3%), fungi (13/203, 6.4%), and mixed infection (25/203, 10.3%). Among bacteria, 79% were gram positive, with Staphylococcus aureus and Streptococcus species being commonest, and 21% were gram negative, with Pseudomonas aeruginosa and Enterobacteriaceae group being the commonest. Aspergillus flavus was the most common fungus isolated. Trend analysis revealed no change in the number of sterile cases and fungal cellulitis. Increase in gram positive bacteria was statistically significant (p = .0002) between 2005-2009 and 2015-2019. The increase in gram negative bacteria was statistically significant (p = .047) between all three time periods. Susceptibility patterns showed increasing trend of resistance to fluoroquinolones, that reached statistical significance for Ciprofloxacin, Moxifloxacin and Gatifloxacin (p < .05). Sterile sample was not found in any of the pediatric (0-16 years) cases (n = 55), compared to 28% in adults.

CONCLUSION

There was a significant rise in gram positive and negative orbital infections over the 15 year period, with increased resistance to fluoroquinolones. Fungal cellulitis and sterile samples showed a steady trend. Orbital aspirate provides accurate detection of the causative organism.

A rare presentation of Klebsiella pneumoniae endogenous panophthalmitis with optic neuritis and orbital cellulitis from a urinary tract infection

This case illustrates the rare presentation of endogenous Klebsiella pneumoniae endophthalmitis with concomitant orbital cellulitis from an acute pyelonephritis. A 59-year-old Caucasian female with type 2 diabetes mellitus was transferred from a regional hospital with decreased visual acuity, periorbital edema, photophobia, proptosis and pain of the right eye, as well as suprapubic discomfort. Initial ocular examination and B-scan ultrasonography were consistent with endophthalmitis and orbital cellulitis which lead to a vitreous tap and intravitreal antibiotics injection and systemic antibiotherapy. Vitreous and blood cultures confirmed Klebsiella pneumoniae as the causative organism. An orbital MRI showed a panophthalmitis with optic neuritis and further imaging confirmed a concomitant pyelonephritis secondary to a septic nephrolithiasis. The patient was given treatment with high-does intravenous antibiotics, oral and topical corticotherapy, and an early core pars plana vitrectomy (PPV), performed 5 days after presentation with repeat injections of antibiotics and dexamethasone. Unfortunately, two weeks following PPV, despite an initial stable postoperative course, the patient deteriorated and presented with purulent discharge from one of the vitrectomy port incision site. An emergency evisceration was performed in order to control the infection, revealing a large subretinal abscess and necrosed sclerotic tissue around the prior vitrectomy incision sites. Conclusion: This is the first case report of Klebsiella pneumoniae endophthalmitis or panophthalmitis presenting with orbital cellulitis and optic neuritis from an urinary tract infection. Prognosis is poor despite treatment including early vitrectomy.

Pseudomonas aeruginosa orbital cellulitis complicated by ophthalmic artery occlusion in an immunocompetent patient: A case report

Introduction

We described a case of a pseudomonas aeruginosa subperiosteal abscess in a healthy adult, complicated by ophthalmic artery occlusion.

Case presentation

A 41-year-old woman presented with the chief complaint of a severe painful left eyelid. The visual acuity was limited to light perception. Fundus examiantion showed diffuse retinal edema, papillary swelling and whitened retinal vessels without cherry-red spot. Multimodal imaging confirmed the diagnosis of ophthalmic artery occlusion. Computed tomography study was performed and objectified a pansinusitis complicated by left orbital cellulitis and a 7.4mm × 29.8 mm subperiosteal abscess (SPA). In addition to intravenous antibiotics, surgical drainage of the SPA was performed. The bacterial culture of the abscess has shown growth of Pseudomonas aeruginosa and laboratories studies did not find any cause of immunodeficiency. Although medical and surgical treatment, the retinal damage was irreversible with visual acuity limited to light perception.

Clinical discussion

The developing of a subperiosteal abscess (SPA) of the orbit is a serious complication that arises usually from bacterial sinusitis and can lead to sight threatening complications. Pseudomonas aeruginosa is not common in healthy adults. An early diagnosis and an adequate treatment are important for the visual prognosis.

Conclusion

Orbital cellulitis should be diagnosed and treated promptly, even in healthy people, to improve visual prognosis.

Clinical, advanced imaging data and outcome of inflammatory and neoplastic orbital disease in 81 dogs and 16 cats in Australia (2010-2019)

OBJECTIVE

To characterize the clinical presentation, advanced imaging features, and outcome of orbital disease in a referral population of dogs and cats that underwent computed tomography (CT) or magnetic resonance imaging (MRI).

ANIMALS STUDIED

Client-owned animals.

PROCEDURES

Animals referred for orbital disease undergoing ophthalmic examination and either head MRI or CT were included. Demographic and imaging features were compared between animals diagnosed with inflammatory disease and neoplastic disease using Mann-Whitney U and Fischer's exact tests.

RESULTS

Ninety-seven animals (81 dogs and 16 cats) were included. Eighty-four and 13 patients underwent CT and MRI scanning, respectively. Inflammatory orbital disease was more frequently detected than neoplasia in dogs (59% vs. 41%) and cats (62% vs. 39%). Orbital cellulitis was the most common diagnosis in dogs (36/81, 44.4%) and cats (8/16, 80%). A foreign body was suspected in 36.1% of dogs with orbital cellulitis but only 3 were retrieved during orbitotomy. Multi-drug resistant bacteria were identified in 3 samples and influenced treatment plans. The most common neoplasms were sarcoma (10/30) and carcinoma (7/30) in dogs and lymphoma in cats (3/6). Imaging findings of osteolysis (p = 0.0002) and intracranial extension (p = 0.0001) were significantly associated with neoplasia in dogs. In contrast, osteolysis extension was present in cats with both inflammatory (7/10) and neoplastic (6/6) orbital disease.

CONCLUSIONS

Inflammatory disease, particularly orbital cellulitis, was more common than neoplasia in dogs and cats with orbital disease in our population. We recommend including bacterial culture and susceptibility as part of the diagnostic work up when orbital cellulitis is suspected.