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Acute Orbital Cellulitis After Peribulbar Injection
LETTERS TO THE JOURNAL Acute Orbital Cellulitis After Peribulbar Injection John D. Hofbauer, M.D., Lynn K. Gordon, M.D., and James Palmer, M.D. Department of Ophthalmology, UCLA School of Medicine and Ophthalmology Section; and Depart ment of Ophthalmology, Wadsworth Veterans Ad ministration Hospital. Inquiries to John Hofbauer, M.D., 416 N. Bedford Dr., Suite 300, Beverly Hills, CA 90210. Orbital cellulitis is an uncommon complica tion of ophthalmic surgery. Orbital cellulitis has been reported after strabismus surgery, 1 · 2 blepharoplasty, 3 and retinal surgery. We exam ined a patient who had acute postoperative orbital cellulitis after peribulbar injection for cataract surgery. A 62-year-old woman underwent combined cataract extraction with intraocular lens inser tion and trabeculectomy in the right eye. A peribulbar injection of 3 ml of lidocaine hydrochloride 1.0% and bupivacaine hydrochloride 0.75% was administered inferiorly and 2 ml was administered superiorly through the hub of a sharp, 1.25-inch, 25-gauge needle after the eyelids were prepared with an alcohol pad. The patient was seen one day after an uncomplicat ed procedure. Uncorrected visual acuity was 20/30. The intraocular pressure was 18 mm Hg. The upper eyelid showed severe edema and erythema. A flat conjunctival bleb was associat ed with moderate hyperemia. The cornea was clear. Trace cell and flare were seen in the
anterior chamber. Results of the remainder of the examination were unremarkable. The pa tient was given prednisolone acetate 1.0% and ciprofloxacin hydrochloride every two hours. Six hours later, the patient reported increased swelling and pain with normal vision. On ex amination, the upper eyelid edema and erythe ma had increased and were associated with moderate chemosis and lower eyelid edema. An erythematous streak, suggestive of Streptococ cus viridans, extended along the lower eyelid. Visual acuity remained 20/30, with minimal anterior chamber reaction. Intraocular pressure was 25 mm Hg and could be lowered to 10 mm Hg by massage. There was 4 mm of axial proptosis. Motility testing showed severe restriction of supraduction, infraduction, and abduction. The patient was admitted to the hospital for intravenous treatment of acute orbital cellulitis. Computed tomography showed the right eye to be proptotic, with extensive right periorbital soft-tissue swelling consistent with cellulitis. No abscess was seen. The adjacent sinuses were clear and without evidence of sinusitis. Culture of the conjunctiva was positive for Staphylococcus epidermidis, though cultures of the nose and pharynx were negative. Blood cultures were also negative. Three hours after institution of therapy, visual acuity was 20/200 with worsen ing ocular motility. There was no relative affer ent pupillary defect, and the reduction in visual acuity was related to corneal changes. Intraocu lar pressure of 40 mm Hg was reduced to 20 mm Hg by ocular massage. Over the next 12 hours, the patient's condition rapidly improved. Intra venous therapy of 1.5 g of ampicillin sodium/
THE JOURNAL welcomes letters that describe unusual clinical or pathologic findings, experimental results, and new instruments or techniques. The title and the names of all authors appear in the Table of Contents and are retrievable through the Index Medicus and other standard indexing services. Letters must not duplicate data previously published or submitted for publication. Each letter must be accompanied by a signed disclosure statement and copyright transfer agreement published in each issue of THE JOURNAL. Letters must be typewritten, double-spaced, on 8 Vi X 11-inch bond paper with 1 Vi-inch margins on all four sides. (See Instructions to Authors.) An original and two copies of the typescript and figures must be sent. The letters should not exceed 500 words of text. A maximum of two black-and-white figures may be used; they should be cropped or reducible to a width of 3 inches (one column). Color figures cannot be used. References should be limited to five. Letters may be referred to outside editorial referees for evaluation or may be reviewed by members of the Editorial Board. All letters are published promptly after acceptance. Authors do not receive galley proofs but if the editorial changes are extensive, the corrected typescript is submitted to them for approval. These instructions markedly limit the opportunity for an extended discussion or review. Therefore, THE JOURNAL does not publish correspondence concerning previously published letters.
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AMERICAN JOURNAL OF OPHTHALMOLOGY
sulbactam every six hours was given for a full five-day course. At the time of discharge, the patient's uncorrected visual acuity was 20/25, with a functioning filtration bleb, and intraocu lar pressure of 17 mm Hg. Orbital cellulitis after cataract surgery with intraocular lens insertion has been reported previously, but symptoms in that case appeared three weeks after surgery and cellulitis was associated with sinus disease. 4 Symptoms in our patient appeared less than 24 hours after the operation and initially were localized to the region of the peribulbar block. Additionally, there was no sinus disease. The diagnosis of orbital cellulitis was made on the basis of periorbital edema and erythema in association with axial proptosis and motility restriction without increased intraocular inflammation. In our pa tient, there also was an increase in intraocular pressure, probably related to increased orbital and venous pressure. Here, a functioning filtra tion bleb was helpful in the rapid reduction of intraocular pressure. The time course and location of this infec tious process implicate the peribulbar injection as the source of infection. It is likely that skin flora inadvertently gained access to the orbit through the peribulbar needle despite a skin preparation with alcohol. Prompt recognition and treatment of the cellulitis resulted in a favorable outcome. However, a more effective skin preparation, such as povidone-iodine, may be warranted in the future to prevent this infec tious complication from injection. 5
References 1. Weakley, D. R.: Orbital cellulitis complicating strabismus surgery. A case report and review of the literature. Ann. Ophthalmol. 23:454, 1991. 2. Wilson, M. E.: Orbital cellulitis following stra bismus surgery. Ophthalmic Surg. 18:92, 1987. 3. Allen, M. V., Cohen, K. L., and Grimson, B. S.: Orbital cellulitis secondary to dacryocystitis follow ing blepharoplasty. Ann. Ophthalmol. 17:498, 1985. 4. Kimbrough, B. O., Young, A. B., and Modica, L. A.: Orbital cellulitis and cavernous sinus thrombo sis after cataract extraction and lens implantation. Ann. Ophthalmol. 24:313, 1992. 5. Apt, L., Isenberg, S. J., Yoshimori, R., and Paez, J. H.: Chemical preparation of the eye in ophthalmic surgery. III. Effect of povidone-iodine on the con junctiva. Arch. Ophthalmol. 102:728, 1984.
September, 1994
Pseudoexfoliation Syndrome Masquerading as Uveitis Kenneth C. Chern, M.D., David M. Meisler, M.D., Edward J. Rockwood, M.D., and Careen Y. Lowder, M.D. Division of Ophthalmology, Cleveland Clinic Foun dation. Inquiries to David M. Meisler, M.D., Division of Oph thalmology, Desk A31, Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195. Pseudoexfoliation syndrome is a condition characterized by the appearance of white flakes of material on anterior segment structures. 1 Deposition of pseudoexfoliative material on the corneal endothelium has been alluded to by others. 1 · 2 In a recent study, the pseudoexfolia tive material appeared to be produced by de generating corneal endothelial cells. 3 We have observed five cases of pseudoexfoliation syn drome, in which pseudoexfoliative material lo cated on the corneal endothelium appeared similar to inflammatory keratic precipitates. The following case is illustrative of this mas querade. A diagnosis of iritis in the right eye was made in a 67-year-old woman because of the finding of numerous white keratic precipitates on the endothelial surface. She had been treated with topical corticosteroids for six months with no improvement in her condition before she was referred to us. Examination disclosed best-cor rected visual acuity of R.E.: 20/50 and L.E.: 20/30. Gray-white particulate flakes, diffusely distributed over the endothelial surface, were observed by slit-lamp biomicroscopy (Fig. 1). The anterior chamber showed no cellular reac-
Fig. 1 (Chern and associates). Pseudoexfoliative material scattered diffusely over the corneal endothe lium.
anterior chamber. Results of the remainder of the examination were unremarkable. The pa tient was given prednisolone acetate 1.0% and ciprofloxacin hydrochloride every two hours. Six hours later, the patient reported increased swelling and pain with normal vision. On ex amination, the upper eyelid edema and erythe ma had increased and were associated with moderate chemosis and lower eyelid edema. An erythematous streak, suggestive of Streptococ cus viridans, extended along the lower eyelid. Visual acuity remained 20/30, with minimal anterior chamber reaction. Intraocular pressure was 25 mm Hg and could be lowered to 10 mm Hg by massage. There was 4 mm of axial proptosis. Motility testing showed severe restriction of supraduction, infraduction, and abduction. The patient was admitted to the hospital for intravenous treatment of acute orbital cellulitis. Computed tomography showed the right eye to be proptotic, with extensive right periorbital soft-tissue swelling consistent with cellulitis. No abscess was seen. The adjacent sinuses were clear and without evidence of sinusitis. Culture of the conjunctiva was positive for Staphylococcus epidermidis, though cultures of the nose and pharynx were negative. Blood cultures were also negative. Three hours after institution of therapy, visual acuity was 20/200 with worsen ing ocular motility. There was no relative affer ent pupillary defect, and the reduction in visual acuity was related to corneal changes. Intraocu lar pressure of 40 mm Hg was reduced to 20 mm Hg by ocular massage. Over the next 12 hours, the patient's condition rapidly improved. Intra venous therapy of 1.5 g of ampicillin sodium/
THE JOURNAL welcomes letters that describe unusual clinical or pathologic findings, experimental results, and new instruments or techniques. The title and the names of all authors appear in the Table of Contents and are retrievable through the Index Medicus and other standard indexing services. Letters must not duplicate data previously published or submitted for publication. Each letter must be accompanied by a signed disclosure statement and copyright transfer agreement published in each issue of THE JOURNAL. Letters must be typewritten, double-spaced, on 8 Vi X 11-inch bond paper with 1 Vi-inch margins on all four sides. (See Instructions to Authors.) An original and two copies of the typescript and figures must be sent. The letters should not exceed 500 words of text. A maximum of two black-and-white figures may be used; they should be cropped or reducible to a width of 3 inches (one column). Color figures cannot be used. References should be limited to five. Letters may be referred to outside editorial referees for evaluation or may be reviewed by members of the Editorial Board. All letters are published promptly after acceptance. Authors do not receive galley proofs but if the editorial changes are extensive, the corrected typescript is submitted to them for approval. These instructions markedly limit the opportunity for an extended discussion or review. Therefore, THE JOURNAL does not publish correspondence concerning previously published letters.
391
392
AMERICAN JOURNAL OF OPHTHALMOLOGY
sulbactam every six hours was given for a full five-day course. At the time of discharge, the patient's uncorrected visual acuity was 20/25, with a functioning filtration bleb, and intraocu lar pressure of 17 mm Hg. Orbital cellulitis after cataract surgery with intraocular lens insertion has been reported previously, but symptoms in that case appeared three weeks after surgery and cellulitis was associated with sinus disease. 4 Symptoms in our patient appeared less than 24 hours after the operation and initially were localized to the region of the peribulbar block. Additionally, there was no sinus disease. The diagnosis of orbital cellulitis was made on the basis of periorbital edema and erythema in association with axial proptosis and motility restriction without increased intraocular inflammation. In our pa tient, there also was an increase in intraocular pressure, probably related to increased orbital and venous pressure. Here, a functioning filtra tion bleb was helpful in the rapid reduction of intraocular pressure. The time course and location of this infec tious process implicate the peribulbar injection as the source of infection. It is likely that skin flora inadvertently gained access to the orbit through the peribulbar needle despite a skin preparation with alcohol. Prompt recognition and treatment of the cellulitis resulted in a favorable outcome. However, a more effective skin preparation, such as povidone-iodine, may be warranted in the future to prevent this infec tious complication from injection. 5
References 1. Weakley, D. R.: Orbital cellulitis complicating strabismus surgery. A case report and review of the literature. Ann. Ophthalmol. 23:454, 1991. 2. Wilson, M. E.: Orbital cellulitis following stra bismus surgery. Ophthalmic Surg. 18:92, 1987. 3. Allen, M. V., Cohen, K. L., and Grimson, B. S.: Orbital cellulitis secondary to dacryocystitis follow ing blepharoplasty. Ann. Ophthalmol. 17:498, 1985. 4. Kimbrough, B. O., Young, A. B., and Modica, L. A.: Orbital cellulitis and cavernous sinus thrombo sis after cataract extraction and lens implantation. Ann. Ophthalmol. 24:313, 1992. 5. Apt, L., Isenberg, S. J., Yoshimori, R., and Paez, J. H.: Chemical preparation of the eye in ophthalmic surgery. III. Effect of povidone-iodine on the con junctiva. Arch. Ophthalmol. 102:728, 1984.
September, 1994
Pseudoexfoliation Syndrome Masquerading as Uveitis Kenneth C. Chern, M.D., David M. Meisler, M.D., Edward J. Rockwood, M.D., and Careen Y. Lowder, M.D. Division of Ophthalmology, Cleveland Clinic Foun dation. Inquiries to David M. Meisler, M.D., Division of Oph thalmology, Desk A31, Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195. Pseudoexfoliation syndrome is a condition characterized by the appearance of white flakes of material on anterior segment structures. 1 Deposition of pseudoexfoliative material on the corneal endothelium has been alluded to by others. 1 · 2 In a recent study, the pseudoexfolia tive material appeared to be produced by de generating corneal endothelial cells. 3 We have observed five cases of pseudoexfoliation syn drome, in which pseudoexfoliative material lo cated on the corneal endothelium appeared similar to inflammatory keratic precipitates. The following case is illustrative of this mas querade. A diagnosis of iritis in the right eye was made in a 67-year-old woman because of the finding of numerous white keratic precipitates on the endothelial surface. She had been treated with topical corticosteroids for six months with no improvement in her condition before she was referred to us. Examination disclosed best-cor rected visual acuity of R.E.: 20/50 and L.E.: 20/30. Gray-white particulate flakes, diffusely distributed over the endothelial surface, were observed by slit-lamp biomicroscopy (Fig. 1). The anterior chamber showed no cellular reac-
Fig. 1 (Chern and associates). Pseudoexfoliative material scattered diffusely over the corneal endothe lium.