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Nonsurgical management of subperiosteal abscess of the orbit: Author’s reply
Ophthalmology Volume 108, Number 7, July 2001 First, among the multiple criteria for their nonsurgical management protocol, the authors are careful to exclude any cases of SPA in children that may be secondary to dental infection, because these cases are more likely to harbor resistant anaerobic infections. We would suggest that the authors’ data on pediatric SPA, as well as our own2 and others,3 limits any management generalizations to those cases specifically secondary to sinusitis. A pediatric orbital infection secondary to any other cause should be managed cautiously, because current data are not available to support any specific management protocol. Second, the authors recommend surgical drainage of pediatric SPA in cases that fail to “defervesce in 36 hours” of medical management. We urge caution with the term “defervesce,” because our experience has shown that several clinical signs are useful, whereas other old standbys may prove unreliable. In particular, the return of appetite after 1 or more days of pretreatment anorexia almost always portends eventual recovery under medical management. In addition, improvement in the range of any pretreatment ocular motility restriction will also predict eventual success. Any improvement, even 5° or 10°, is significant, and we recommend careful repeated measurements by the same ophthalmologist each time, because only this individual can note such improvement with certainty. On the other hand, periorbital edema and eyelid swelling often will fail to improve or will even increase the day after successful treatment. This is presumably because of the large volume of intravenous fluids given along with antibiotics to these uniformly dehydrated children. The typical recumbent position of the hospitalized patient adds to the periorbital fluid collection. Likewise, radiologic findings are affected, and repeat computed tomography scans may show failure to resolve, worsening, or even emergence of a new subperiosteal fluid collection, despite effective infection control. Several authors have documented such “sterile abscesses” when drained.3,4 Increased eye swelling with SPA enlargement despite antibiotics is a traditional criterion for surgical drainage. However, we have observed such patients eating breakfast for the first time in 2 days, with improved eye motions revealed once the eyelids were pried open. These were successfully managed medically. Last, as the authors point out, children older than 9 years of age with SPA may, indeed, be managed medically, although with more caution than those in the younger age group. The authors exclude those who show no “clinical improvement in 72 hours” from further medical management. In our experience, such older children often require longer courses of treatment, and “defervesce” more slowly, sometimes requiring well over a week of treatment before fever and swelling are significantly resolved. One teenager we treated resumed eating well 2 days after intravenous antibiotics began and “felt fine” despite prominent proptosis and pain to globe retropulsion, which took over a month to resolve. Currently, the bulk of data supports surgical drainage of SPA, because few have documented medical management in the pediatric age group. Some believe pediatric SPA may be more dangerous because vision cannot accurately be
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followed in young children. Dr. Harris’ elegant study of age-dependent bacteriologic differences within SPAs explains why pediatric cases respond differently than adult cases.4 We congratulate the authors on this new, excellent prospective study and applaud their efforts to develop guidelines in which medical management is safest. However, their data should not be interpreted to suggest that surgery is indicated for those outside the guidelines, because many of these may also be managed medically. MARC F. GREENBERG, MD ZANE F. POLLARD, MD Atlanta, Georgia References 1. Garcia GH, Harris GJ. Criteria for nonsurgical management of subperiosteal abscess of the orbit: analysis of outcomes 1988 – 1998. Ophthalmology 2000;107:1454 – 6; discussion 1457– 8. 2. Greenberg MF, Pollard ZF. Medical treatment of pediatric subperiosteal orbital abscess secondary to sinusitis. J AAPOS 1998;2:351–5. 3. Rubin SE, Rubin LG, Zito J, et al. Medical management of orbital sub-periosteal abscess in children. J Pediatr Ophthalmol Strabismus 1989;26:21–7. 4. Harris GJ. Subperiosteal abscess of the orbit. Age as a factor in the bacteriology and response to treatment. Ophthalmology 1994;101:585–95.
Author’s reply Dear Editor: To address the individual concerns of Drs. Greenberg and Pollard, we would like to restate the context and purpose of our study. Our interest in subperiosteal abscess (SPA) has been ongoing for almost 20 years.1–7 Before and during much of that interval, treatment recommendations for the various stages of orbital cellulitis were generally polarized along specialty lines. Pediatricians advocated a conservative medical approach, whereas surgeons recommended prompt drainage of the sinuses and orbital abscesses. Early on, we were struck by age-related differences in clinical response, and we investigated age as one factor to help rationalize the treatment of this complex condition. We found that patients in the first decade of life generally had infections caused by single aerobic pathogens, which were usually responsive to medical therapy alone. Patients older than 15 years of age had complex infections caused by multiple aerobic and anaerobic organisms, which were slow to clear despite medical and surgical intervention. At that time, the youngest patient in our series with anaerobic pathogens was 9 years of age. On the basis of our retrospective analysis of clinical and bacteriologic data in 37 cases, we proposed management guidelines.3,4 From 1988 to 1998, we prospectively applied those guidelines, and our recent publication7 reports the outcomes of that study. Because the microbiologic and clinical reasoning behind our management protocols was detailed in the earlier work, a full-text repetition in the most recent article would have been redundant. We are gratified that Drs. Greenberg and Pollard confirmed the findings of our 1993 study3 in their 1998 article,8 and that they reiterated our rationale for an age-related therapeutic approach.
Letters to the Editor In their letter, Drs. Greenberg and Pollard question our inclusion of infections of dental origin as surgical criteria in this context. Perhaps we did not clearly identify this small subset of subjects as having sinusitis of dental origin as the proximate cause of their SPAs. Our reasoning for the prompt drainage of anaerobic infection (i.e., the toxic effect of oxygen on the pathogens) applies to any SPA in which anaerobes are highly predictable. Drs. Greenberg and Pollard question our recommendation that patients who fail to defervesce with 36 hours should default to surgery. In doing so, they have introduced some other clinical signs, including return of appetite and slight improvement in motility, which they have observed in recovering subjects. They also note that clinical signs and computed tomography findings may worsen despite infection control. Our concern about fever and our recognition of the variations in the bacteriologic, clinical and radiologic time-courses relate to the pharmacokinetics of antibiotic administration and have been detailed in our earlier publications.3,5 Time is required for therapeutic levels of antibiotics to be achieved within the relatively avascular subperiosteal space. Therefore, the infection may progress within the first 24 hours or more of treatment, despite its ultimate resolution with medical therapy alone. We generally associate persistent fever with ongoing bacteremia, and we believe that a correct choice of antibiotics should control the bacteremia well before eradicating the more sequestered sinus and orbital infection. Persistent fever beyond 36 hours of treatment causes us concern about the efficacy of our medical therapy. Last, they note that children older than 9 years of age may be managed medically. We have no disagreement in that regard and so stated in our article.7 It is important to recognize that SPA of the orbit represents a spectrum of disease. At one extreme are patients who will recover promptly with antibiotic therapy alone. At the other, are patients who will be refractory to both medical and surgical therapy and may rapidly go on to life-threatening complications, such as brain abscesses. The therapeutic choice between early surgical drainage of the sinuses and orbit versus medical therapy with observation, is ultimately up to the managing physicians. We have tried to introduce criteria, including patient age, that are intended as general guidelines for those decisions. Clearly, there are some patients less than 9 years of age who will require surgery. Conversely, there are patients older than 9 years of age who will respond to medical treatment. We do believe, however, that there may be a “sliding scale” of risk associated with increasing age. GERALD J. HARRIS, MD Milwaukee, Wisconsin GEORGE H. GARCIA, MD Orange, California References 1. Harris GJ. Subperiosteal abscess of the orbit. Arch Ophthalmol 1983;101:751–7. 2. Harris GJ. Subperiosteal inflammation of the orbit. A bacteriological analysis of 17 cases. Arch Ophthalmol 1988;106:947– 52.
3. Harris GJ. Age as a factor in the bacteriology and response to treatment of subperiosteal abscess of the orbit. Trans Am Ophthalmol Soc 1993;91:441–516. 4. Harris GJ. Subperiosteal abscess of the orbit. Age as a factor in the bacteriology and response to treatment. Ophthalmology 1994;101:585–95. 5. Harris GJ. Subperiosteal abscess of the orbit: computed tomography and the clinical course. Ophthal Plast Reconstr Surg 1996;12:1– 8. 6. Harris GJ, Bair RL. Anaerobic and aerobic isolates from a subperiosteal orbital abscess in a 4-year-old [letter]. Arch Ophthalmol 1996;114:98. 7. Garcia GH, Harris GJ. Criteria for nonsurgical management of subperiosteal abscess of the orbit: analysis of outcomes 1988 – 1998. Ophthalmology 2000;107:1454 – 6; discussion 1457– 8. 8. Greenberg MF, Pollard ZF. Medical treatment of pediatric subperiosteal orbital abscess secondary to sinusitis. J AAPOS 1998;2:351–5.
Ocular Injuries Caused by Intraocular or Retrobulbar Foreign Bodies The following three letters address an article that appeared in the May 2000 issue of the Journal: Jonas JB, Knorr HLJ, Budde WM. Prognostic factors in ocular injuries caused by intraocular or retrobulbar foreign bodies. (Ophthalmology 2000;107:823– 8) Dear Editor: In the article “Prognostic Factors in Ocular Injuries Caused by Intraocular or Retrobulbar Foreign Bodies” the authors reported on their extensive experience with open-globe injuries and intraocular foreign bodies and analyzed the results to determine the prognostic factors in such cases. Only two of the authors had been credited for performing all the operations during their every-other-night call schedule, and no comparison was made between the outcomes of the surgeries performed by these two surgeons. However, as a part of their discussion, the authors stated, “experience of the surgeon may have a much greater impact on the final result than the timing of the operation.” The basis for making such a statement in this cross-sectional study is uncertain to me. It appears to be a common trend in the Ophthalmology and other peer-reviewed journals that some authors mention the extent of their surgical experience and number of cases performed while reporting on a wide variety of topics. Such statements may be perceived as self-promotional and do not seem to serve any other purpose. This trend is more noticeable in the field of refractive surgery. As some surgeons perform more cases and report on their results, it appears that the definition of an “experienced surgeon” changes rapidly.1 No one can deny the great importance of experience, especially in a surgical field such as ophthalmology. Furthermore, any physician has the right to be proud of his or her clinical or surgical achievements. However, the significance of arbitrary and subjective statements about surgical experience in a scientific journal such as Ophthalmology is unclear. The responsible surgeons who strongly believe in the importance of experience as a prerequisite for the practice
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followed in young children. Dr. Harris’ elegant study of age-dependent bacteriologic differences within SPAs explains why pediatric cases respond differently than adult cases.4 We congratulate the authors on this new, excellent prospective study and applaud their efforts to develop guidelines in which medical management is safest. However, their data should not be interpreted to suggest that surgery is indicated for those outside the guidelines, because many of these may also be managed medically. MARC F. GREENBERG, MD ZANE F. POLLARD, MD Atlanta, Georgia References 1. Garcia GH, Harris GJ. Criteria for nonsurgical management of subperiosteal abscess of the orbit: analysis of outcomes 1988 – 1998. Ophthalmology 2000;107:1454 – 6; discussion 1457– 8. 2. Greenberg MF, Pollard ZF. Medical treatment of pediatric subperiosteal orbital abscess secondary to sinusitis. J AAPOS 1998;2:351–5. 3. Rubin SE, Rubin LG, Zito J, et al. Medical management of orbital sub-periosteal abscess in children. J Pediatr Ophthalmol Strabismus 1989;26:21–7. 4. Harris GJ. Subperiosteal abscess of the orbit. Age as a factor in the bacteriology and response to treatment. Ophthalmology 1994;101:585–95.
Author’s reply Dear Editor: To address the individual concerns of Drs. Greenberg and Pollard, we would like to restate the context and purpose of our study. Our interest in subperiosteal abscess (SPA) has been ongoing for almost 20 years.1–7 Before and during much of that interval, treatment recommendations for the various stages of orbital cellulitis were generally polarized along specialty lines. Pediatricians advocated a conservative medical approach, whereas surgeons recommended prompt drainage of the sinuses and orbital abscesses. Early on, we were struck by age-related differences in clinical response, and we investigated age as one factor to help rationalize the treatment of this complex condition. We found that patients in the first decade of life generally had infections caused by single aerobic pathogens, which were usually responsive to medical therapy alone. Patients older than 15 years of age had complex infections caused by multiple aerobic and anaerobic organisms, which were slow to clear despite medical and surgical intervention. At that time, the youngest patient in our series with anaerobic pathogens was 9 years of age. On the basis of our retrospective analysis of clinical and bacteriologic data in 37 cases, we proposed management guidelines.3,4 From 1988 to 1998, we prospectively applied those guidelines, and our recent publication7 reports the outcomes of that study. Because the microbiologic and clinical reasoning behind our management protocols was detailed in the earlier work, a full-text repetition in the most recent article would have been redundant. We are gratified that Drs. Greenberg and Pollard confirmed the findings of our 1993 study3 in their 1998 article,8 and that they reiterated our rationale for an age-related therapeutic approach.
Letters to the Editor In their letter, Drs. Greenberg and Pollard question our inclusion of infections of dental origin as surgical criteria in this context. Perhaps we did not clearly identify this small subset of subjects as having sinusitis of dental origin as the proximate cause of their SPAs. Our reasoning for the prompt drainage of anaerobic infection (i.e., the toxic effect of oxygen on the pathogens) applies to any SPA in which anaerobes are highly predictable. Drs. Greenberg and Pollard question our recommendation that patients who fail to defervesce with 36 hours should default to surgery. In doing so, they have introduced some other clinical signs, including return of appetite and slight improvement in motility, which they have observed in recovering subjects. They also note that clinical signs and computed tomography findings may worsen despite infection control. Our concern about fever and our recognition of the variations in the bacteriologic, clinical and radiologic time-courses relate to the pharmacokinetics of antibiotic administration and have been detailed in our earlier publications.3,5 Time is required for therapeutic levels of antibiotics to be achieved within the relatively avascular subperiosteal space. Therefore, the infection may progress within the first 24 hours or more of treatment, despite its ultimate resolution with medical therapy alone. We generally associate persistent fever with ongoing bacteremia, and we believe that a correct choice of antibiotics should control the bacteremia well before eradicating the more sequestered sinus and orbital infection. Persistent fever beyond 36 hours of treatment causes us concern about the efficacy of our medical therapy. Last, they note that children older than 9 years of age may be managed medically. We have no disagreement in that regard and so stated in our article.7 It is important to recognize that SPA of the orbit represents a spectrum of disease. At one extreme are patients who will recover promptly with antibiotic therapy alone. At the other, are patients who will be refractory to both medical and surgical therapy and may rapidly go on to life-threatening complications, such as brain abscesses. The therapeutic choice between early surgical drainage of the sinuses and orbit versus medical therapy with observation, is ultimately up to the managing physicians. We have tried to introduce criteria, including patient age, that are intended as general guidelines for those decisions. Clearly, there are some patients less than 9 years of age who will require surgery. Conversely, there are patients older than 9 years of age who will respond to medical treatment. We do believe, however, that there may be a “sliding scale” of risk associated with increasing age. GERALD J. HARRIS, MD Milwaukee, Wisconsin GEORGE H. GARCIA, MD Orange, California References 1. Harris GJ. Subperiosteal abscess of the orbit. Arch Ophthalmol 1983;101:751–7. 2. Harris GJ. Subperiosteal inflammation of the orbit. A bacteriological analysis of 17 cases. Arch Ophthalmol 1988;106:947– 52.
3. Harris GJ. Age as a factor in the bacteriology and response to treatment of subperiosteal abscess of the orbit. Trans Am Ophthalmol Soc 1993;91:441–516. 4. Harris GJ. Subperiosteal abscess of the orbit. Age as a factor in the bacteriology and response to treatment. Ophthalmology 1994;101:585–95. 5. Harris GJ. Subperiosteal abscess of the orbit: computed tomography and the clinical course. Ophthal Plast Reconstr Surg 1996;12:1– 8. 6. Harris GJ, Bair RL. Anaerobic and aerobic isolates from a subperiosteal orbital abscess in a 4-year-old [letter]. Arch Ophthalmol 1996;114:98. 7. Garcia GH, Harris GJ. Criteria for nonsurgical management of subperiosteal abscess of the orbit: analysis of outcomes 1988 – 1998. Ophthalmology 2000;107:1454 – 6; discussion 1457– 8. 8. Greenberg MF, Pollard ZF. Medical treatment of pediatric subperiosteal orbital abscess secondary to sinusitis. J AAPOS 1998;2:351–5.
Ocular Injuries Caused by Intraocular or Retrobulbar Foreign Bodies The following three letters address an article that appeared in the May 2000 issue of the Journal: Jonas JB, Knorr HLJ, Budde WM. Prognostic factors in ocular injuries caused by intraocular or retrobulbar foreign bodies. (Ophthalmology 2000;107:823– 8) Dear Editor: In the article “Prognostic Factors in Ocular Injuries Caused by Intraocular or Retrobulbar Foreign Bodies” the authors reported on their extensive experience with open-globe injuries and intraocular foreign bodies and analyzed the results to determine the prognostic factors in such cases. Only two of the authors had been credited for performing all the operations during their every-other-night call schedule, and no comparison was made between the outcomes of the surgeries performed by these two surgeons. However, as a part of their discussion, the authors stated, “experience of the surgeon may have a much greater impact on the final result than the timing of the operation.” The basis for making such a statement in this cross-sectional study is uncertain to me. It appears to be a common trend in the Ophthalmology and other peer-reviewed journals that some authors mention the extent of their surgical experience and number of cases performed while reporting on a wide variety of topics. Such statements may be perceived as self-promotional and do not seem to serve any other purpose. This trend is more noticeable in the field of refractive surgery. As some surgeons perform more cases and report on their results, it appears that the definition of an “experienced surgeon” changes rapidly.1 No one can deny the great importance of experience, especially in a surgical field such as ophthalmology. Furthermore, any physician has the right to be proud of his or her clinical or surgical achievements. However, the significance of arbitrary and subjective statements about surgical experience in a scientific journal such as Ophthalmology is unclear. The responsible surgeons who strongly believe in the importance of experience as a prerequisite for the practice
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