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Outcome of Treated Orbital Cellulitis in a Tertiary Eye Care Center in the Middle East
Outcome of Treated Orbital Cellulitis in a Tertiary Eye Care Center in the Middle East Imtiaz A. Chaudhry, MD, PhD,1 Farrukh A. Shamsi, MPhil, PhD,2 Elsanusi Elzaridi, MD,3 Waleed Al-Rashed, MD,1 Abdulrahman Al-Amri, MD,4 Fahad Al-Anezi, MD,4 Yonca O. Arat, MD,5 David E. Holck, MD6 Purpose: To describe risk factors predisposing patients to orbital cellulitis and potential complications in patients treated at a tertiary eye care referral center in the Middle East. Design: Noncomparative, interventional, retrospective case series. Participants: Patients diagnosed with orbital cellulitis. Methods: A 15-year clinical review of patients with a diagnosis of orbital cellulitis referred to King Khaled Eye Specialist Hospital, an accredited (Joint Council on Accreditation of Healthcare Organizations, Washington, DC) tertiary care center in Riyadh, Saudi Arabia, was performed. Only those patients who had clinical signs and symptoms or radiologic evidence suggestive of orbital cellulitis were included in the study. Main Outcome Measures: Patient demographics, factors predisposing to orbital cellulitis, and resulting complications. Results: A total of 218 patients (136 male, 82 female) fulfilling the diagnostic criteria for orbital cellulitis were identified. The average age of these patients was 25.7 years (range, 1 month– 85 years). On imaging studies, there was evidence of inflammatory or infective changes to orbital structures; orbital abscesses were identified in 116 patients (53%). Sinus disease was the most common predisposing cause in 86 patients (39.4%), followed by trauma in 43 patients (19.7%). All patients received systemic antibiotic treatment before the identification of any responsible organisms. Of the 116 patients with orbital abscess, 101 patients (87%) required drainage. The results of cultures in patients in whom an orbital abscess was drained were positive for 91 patients (90%). The most common microorganisms isolated from the drained abscesses were Staphylococci and Streptococci species. Blood cultures were positive in only 4 patients from whom blood was drawn for cultures. Visual acuity improved in 34 eyes (16.1%) and worsened in 13 eyes (6.2%), including 9 (4.3%) eyes that sustained complete loss of vision, which was attributed to the delay in correct diagnosis and timely intervention (average 28 days vs. 9 days in patients with no loss of vision; P⬍0.05). There were 9 cases of intracranial extension of orbital abscesses that required either extended treatment with systemic antibiotics alone or in combination with neurosurgical intervention. Most patients received oral antibiotics on discharge for varying periods. There were 6 cases (2.7%) of strabismus and 4 cases (1.8%) of ptosis that persisted after treatment and resolution of orbital cellulitis. Conclusions: Untreated sinusitis and prior history of orbital trauma were the 2 major causes of orbital cellulitis in patients referred to a tertiary care eye center in the Middle East. Although rare, severe visual loss still remains a serious complication of delayed detection and intervention in most cases of orbital cellulitis. Ophthalmology 2007;114:345–354 © 2007 by the American Academy of Ophthalmology.
Orbital cellulitis is a relatively uncommon infectious process previously associated with severe complications involving ocular adnexal structures posterior to the orbital septum.1 It is primarily a disease of children and young adults, with a peak incidence in the 0- to 15-year age group.2 The most common predisposing factor is sinus
disease, particularly in the younger age groups.1–3 Less common risk factors include periocular trauma, prior history of surgery, dacryocystitis, retained orbital foreign body, recent history of dental infection, endophthalmitis, bacterial endocarditis, and intraocular and orbital tumors.4 –11 In the past, orbital cellulitis has been associated
Originally received: May 17, 2006. Accepted: July 12, 2006.
5
Manuscript no. 2006-543.
1
Oculoplastic and Orbit Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia.
2
Research Department, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia.
3
Royal Eye Infirmary, New Castle-upon-Tyne, United Kingdom.
4
Department of Ophthalmology, King Saud University, Riyadh, Saudi Arabia.
© 2007 by the American Academy of Ophthalmology Published by Elsevier Inc.
Department of Ophthalmology, Baylor College of Medicine, Houston, Texas. Department of Ophthalmology, Wilford Hall Medical Center, San Antonio, Texas. Presented at: American Academy of Ophthalmology Annual Meeting, October 2005, Chicago, Illinois. The authors have no propriety interests related to the study. Correspondence to Imtiaz A. Chaudhry, MD, PhD, Oculoplastic and Orbit Division, King Khaled Eye Specialist Hospital, P.O. Box 7191, Riyadh 11462, Saudi Arabia. E-mail: [email protected].
6
ISSN 0161-6420/07/$–see front matter doi:10.1016/j.ophtha.2006.07.059
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Ophthalmology Volume 114, Number 2, February 2007 Table 1. Presenting Signs and Symptoms of Orbital Cellulitis Signs and Symptoms Swelling Proptosis Restricted motility Pain Decreased VA Ptosis Headache Diplopia RAPD
No. of Patients
Percentage
156 149 129 114 31 23 22 14 12
71.5 68.3 59.2 52.3 14.2 10.6 10.1 6.4 5.5
RAPD ⫽ relative afferent pupillary defect; VA ⫽ visual acuity.
cations of intracranial abscess have been found as a result of cavernous sinus thrombosis and intracranial rupture of the abscess.15 Most of the previous studies of orbital cellulitis have come from Western countries, and studies from developing countries have been reported rarely in the literature.16,17 The purpose of this study was to review the clinical records of patients referred to King Khaled Eye Specialist Hospital, an accredited (Joint Council on Accreditation of Healthcare Organizations, Washington, DC) tertiary eye care referral center in Riyadh, Saudi Arabia, with the diagnosis of orbital cellulitis to determine the predisposing risk factors and outcomes of treatment.
Patients and Methods with a number of serious complications, including loss of visual acuity, cavernous sinus thrombosis, meningitis, frontal abscess, osteomyelitis, and even death.12 Since the advent of effective antibiotic treatments, these serious complications have become much less frequent.13 From the past series in which final visual results have been reported, a significant percentage of patients were left with blind eyes, ranging anywhere from 7.1% to as high as 23.6%.14 Fatal compli-
After obtaining approval from the institutional review board, a retrospective review was made of the medical records of all patients admitted to the King Khaled Eye Specialist Hospital with a diagnosis of orbital cellulitis under the Diagnostic Related Group coding for the past 15 years. The search was performed in a computerized database of all patients with diagnosis of orbital cellulitis. The clinical charts were reviewed for patient demographics such as age, gender, and presence of the following clinical
Figure 1. A, Photograph of a 12-year-old girl with 2-week history of sinusitis and orbital cellulitis at initial presentation. B, Photograph obtained 48 hours after beginning intravenous antibiotics showing that the patient’s left-sided orbital cellulitis worsened with increased proptosis, chemosis, and ophthalmoplegia. C, Repeat computed tomographic scan revealing an increase in left orbital abscess requiring urgent drainage. D, Photograph of the same patient 2 days after drainage of left orbital abscess.
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Chaudhry et al 䡠 Outcome of Treated Orbital Cellulitis Table 2. Causes of Orbital Cellulitis (n ⫽ 214) Location
No. of Patients
Percentage
Sinusitis Trauma Endophthalmitis Orbital implants Dacryocystitis Dental infection Retained foreign body Scleral buckle Sinusitis and trauma Tumors* Others†
86 43 29 18 10 6 7 5 9 8 11
39.4 19.7 13.3 8.2 4.6 2.7 3.2 2.3 4.1 3.7 5.1
*Retinoblastoma, n ⫽ 6; rhabdomyosarcoma, n ⫽ 1; melanoma, n ⫽ 1. † Exenterated sockets, n ⫽ 4; aqueous drainage devices, n ⫽ 2; insect bite, n ⫽ 1; topical neomycin drops, n ⫽ 2; strabismus surgery, n ⫽ 1; keratoprosthesis, n ⫽ 1.
features: external ophthalmoplegia, proptosis, chemosis, decreased visual acuity, and any radiologic evidence of orbital inflammation, sinusitis, and intracranial or orbital abscess. Only patients fulfilling the diagnostic criteria for orbital cellulitis, such as ophthalmoplegia, proptosis, chemosis, decreased visual acuity, or radiologic evidence of orbital inflammation or abscess, were included in the study. Predisposing factors such as sinusitis, previous history of trauma, surgery, dacryocystitis, or dental abscess were investigated. Information regarding the use of systemic (oral or intravenous) antibiotics before admission, during admission, and at discharge was gathered. Snellen visual acuity as well as ocular examination of these patients were reviewed from first presentation and the last follow-up examination, either at the time of discharge or as outpatient, where recorded. Operative notes were reviewed regarding the procedure performed in those patients where orbital abscesses were drained. Patients in whom no surgical intervention was performed and who improved were identified on the basis of clinical and imaging studies, including resolution of orbital abscess. The microbiology results were studied for the growth of microorganisms from the surgically drained abscesses where cultures were performed. In cases where the microorganisms were identified from abscess cultures, the organisms were investigated and cases of mixed aerobes and anaerobes identified. Patients with any visual impairment resulting from orbital cellulitis were identified before and after completion of treatment, and their risk factors were studied. Complications after resolution of orbital cellulitis were noted either on discharge or at last outpatient follow-up. In particular, complications such as reduction in Snellen visual acuity, repeat infection, intracranial extension, loss of ocular motility, and persistent ptosis were noted. Table 3. Surgeries Performed (n ⫽ 159 Orbits)
Table 4. The Most Common Microorganisms Isolated from Orbital Abscess (n ⫽ 91) Percentage Microorganism Isolated
No. of Isolates Overall Within Group
Gram positive Staphylococcus aureus Staphylococcus epidermidis Streptococcus pneumoniae Streptococcus viridans Streptococcus pyogenes -hemolytic streptococcus A Other Streptococci species Gram negative Haemophilus influenza Pseudomonas species Escherichia coli Eikenella species Actinobacter species Corynebacterium species Morexella species Enterobacter species Others Anaerobes Propionibacterium acnes Peptostreptococcus species Veillonella species Fungi
23 18 9 7 4 4 11
16.7 13.1 6.5 5 3 3 8
30.2 23.6 11.8 9.2 5.2 5.2 14.5
6 4 4 3 1 2 2 2 4
4.3 3 3 2.1 ⬍1 1.5 1.5 1.5 3
21.4 14.3 14.3 10.7 3.5 7 7 7 14.3
11 1 1 8
12 ⬍1 ⬍1 8.8
84.6 7.7 7.7 NA
NA ⫽ not applicable.
Results A total of 218 patients (136 male, 82 female; 4 bilateral) fulfilling the diagnostic criteria for orbital cellulitis were identified. The average age of these patients was 25.7 years (range, 1 month– 85 years). In total, 114 patients (52%) were younger than 16 years of age. The right side was involved in 110 orbits (50.5%), and the left was involved in 108 orbits (49.5%). Presenting signs included eyelid swelling in 156 (71.5%), proptosis in 149 (68.3%), motility restriction in 129 (59.2%), pain in 114 (52.3%), and decreased visual acuity in 31 (14.2%) cases (Table 1). Diagnosis was made clinically and was confirmed by computed tomography (CT) scans or ultrasonography in 197 (90.4%) and 79 (36.2%) orbits, respectively. Orbital abscesses (Fig 1) were identified in 116 (53.2%) orbits. In all cases of orbital cellulitis, there was evidence of inflammatory or infective changes to orbital structures. Abscess location was found to be medial in 40 orbits (35%), superior in 38 orbits (33%), intraconal in 15 orbits (13%), superomedial in 7 orbits (6%), inferomedial in 7 orbits (6%), lateral in 2 orbits (1.7%), and unspecified in Table 5. Visual Acuity of Patients Treated for Orbital Cellulitis*
Procedure
No. of Patients
Percentage
Abscess drainage* Evisceration Enucleation Implant removal Exenteration† Dacryocystorhinostomy
101 21 18 6 7 6
46.3 9.6 8.2 2.7 3.2 2.7
*Fifteen abscesses not drained; culture positive from 91 specimens. † Orbital exenteration performed for fungal infection in 6 patients and for Wegener’s granuloma in 1 patient.
Snellen Visual Acuity 20/20–20/40 20/60–20/100 20/200–20/400 CF–LP Not taken
Initial Visual Acuity
Final Visual Acuity
63 23 4 12 14
88 5 3 7 1
CF ⫽ counting fingers; LP ⫽ light perception. *Not included were pediatric visual acuity and patients with orbital cellulitis secondary to endophthalmitis.
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Ophthalmology Volume 114, Number 2, February 2007 Table 6. Complications of Orbital Cellulitis (n ⫽ 218) Complication
No. of Patients
Percentage
Vision loss* Intracranial abscess extension Repeat infection Infected implant removal† Strabismus Persistent ptosis‡
13 9 9 6 6 4
6 4.1 4.1 2.7 2.7 1.8
*Includes complete loss of vision in 9 eyes, residual visual field defects in 2 eyes, and decreased visual acuity in 2 eyes resulting from corneal scar from exposure keratopathy. † Implants not exposed. ‡ Ptosis persisted more than 7 months after treatment of orbital cellulitis.
7 orbits (6%). In addition to orbital involvement, intracranial abscess was found in 9 patients (7.7%). Sinus disease was the most common predisposing cause in 86 patients (39.4%), trauma in 43 patients (19.7%), endophthalmitis in 29 patients (13.3%), orbital implants in 18 patients (8.2%), dacryocystitis in 10 patients (4.6%), retained orbital foreign body in 7 patients (3.2%; Fig 2), dental infection in 6 patients (2.7%), and scleral buckle in 5 patients (2.3%; Table 2). A history of sinusitis and recent trauma was the cause of orbital cellulitis in 9 patients (4.1%; Fig 3), and intraocular or orbital tumors were the cause in 8 patients (3.7%; 6 retinoblastomas, 1 rhabdomyosarcoma, and 1 melanoma) with orbital cellulitis.18 Less common were 11 patients (5%) who accounted for 4 exenterated orbital sockets, 2 orbits with previously implanted aqueous drainage devices, allergic reaction to topical neomycin drops in 2 orbits, recent strabismus surgery in 1 patient, keratoprosthesis in 1 patient, and a recent history of insect bite in another patient. All patients received systemic antibiotic treatment, and in all patients, treatment regimens were empirically based and were instituted before the identification of any responsible organisms. The most common antibiotic regimen included cephalosporins in 196 patients (90%), and aminoglycosides in 144 patients (66%) with a combination of other antibiotics. These antibiotics included flucloxacillin in 32 patients (15%), vancomycin in 29 patients
(13%), ampicillin in 13 patients (6%), metronidazole in 8 patients (4%), and penicillin in 6 patients (3%). Among the 116 radiologically confirmed orbital abscesses, 101 (87%) required drainage, and the remaining 15 (13%) were observed closely until their resolution while those patients were treated with systemic antibiotics. Thirty-nine eyes (17.8%) had endophthalmitis causing orbital cellulitis and required evisceration (21 [9.6%]) or enucleation (18 [8.2%]). Seven orbits (3.2%) required exenteration (Fig 4) and 6 (2.7%) infected orbital implants had to be removed (Fig 5). Six patients (2.7%) had dacryocystitis that required a dacryocystorhinostomy to treat orbital cellulitis in addition to the systemic antibiotics (Table 3). Combined endoscopic sinus surgery with transnasal orbital abscess drainage was carried out in some of our patients with sinusitis and orbital abscess, especially in the medial orbit. Cultures were performed in all patients in whom an orbital abscess was drained, and results were positive in 91 patients (90%). The most common microorganisms isolated from the drained abscesses were Staphylococci and Streptococci species; less common organisms included Propionibacterium acnes, Haemophilus influenzae, Bacillus, and fungi (Table 4). In addition to CT scans, magnetic resonance imaging studies with fat suppression at 2- to 3-mm cuts were useful for visualizing the intracranial component of abscess in addition to suspected orbital abscess. No specific species or combination of organisms was found to predominate; however, Staphylococci and Streptococci species were encountered more often. Blood cultures were positive in only 4 of 50 patients from whom blood was drawn for cultures. Thirteen patients (6.2%) required changes in their systemic antibiotics based on culture results or on no response to the initial antibiotics. Visual acuity improved in 34 eyes (16.1%) and worsened in 13 eyes (6.2%), including 9 eyes (4.3%) that sustained complete loss of vision (Tables 5, 6). The permanent loss of vision was attributed to the delay in diagnosis and intervention (Table 7). There were 9 cases of intracranial extension of orbital abscesses that required either extended treatment with systemic antibiotics alone or in combination with neurosurgical intervention (Fig 6). The average hospital stay was 8.9 days (range, 1–28 days). Most patients received oral antibiotics on discharge for varying periods, ranging from 3 days to 3 weeks. Repeat orbital cellulitis was found in 9 patients (4.1%; Fig 7). Table 7. Characteristics of Patients with Complete
Patient No.
Age (yrs)
Gender
Eye
1
60
M
R
Sinusitis
Decreased VA, pain, proptosis, decreased EOM
2 3
36 20
F F
L R
Chronic dacryocystitis Dental infection
Decreased VA, proptosis, decreased EOM Decreased VA, proptosis, decreased EOM
4
65
F
R
CE/IOL, IDDM
Decreased VA, pain, proptosis, decreased EOM
7 days
5
9
M
L
Trauma, R/O, rhabdomyosarcoma
Pain, proptosis, decreased EOM
1 mo
6
27
F
L
Sinusitis, trauma
Decreased VA, pain, proptosis
7 days after trauma
7
75
F
R
Sinusitis, DM, HTN
Decreased VA, pain, decreased EOM
25 days
8
30
M
L
Chickenpox
Decreased VA, pain, proptosis, decreased EOM
14 days
9
51
M
R
Sinusitis, DM, HTN
Decreased VA, proptosis
10 days
History
Symptoms
Duration 4 mos 14 days 1 mo
CE/IOL ⫽ cataract extraction/intraocular lens implantation; CRAO/CRVO ⫽ central retinal artery occlusion/central retinal vein occlusion; DM ⫽ insulin-dependent diabetes mellitus; L ⫽ left; M ⫽ male; NR ⫽ not reported; R ⫽ right; RAPD ⫽ relative afferent pupillary defect; R/O ⫽ rule out; SPA ⫽
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Chaudhry et al 䡠 Outcome of Treated Orbital Cellulitis There were 6 cases of strabismus and 4 cases of ptosis that persisted more than 7 months after the treatment of orbital cellulitis. The average follow-up of these patients was 19 months (range, 1 week–12 years).
Discussion The results from this study confirm previous observations from Western countries in which sinus infection has been implicated as the cause of orbital cellulitis in most of the reported cases.13,19,20 Particularly in the pediatric population, up to 90% of patients with orbital cellulitis have existing sinusitis, with almost half having multiple sinus involvement.2 Unlike patients in Western countries, most patients with sinusitis and orbital cellulitis sought treatment later in the course of their disease in our study. The health care system in the Kingdom of Saudi Arabia has a 3-step referral process, with primary care physicians initially screening the patients. King Khaled Eye Specialist Hospital in Riyadh, the only major eye care hospital in the country, provides tertiary orbital care for most of the population of Saudi Arabia.17 Therefore, this study of 218 patients with orbital cellulitis over a 15-year period represents most of the patients who were referred to a tertiary eye care center. After sinusitis, periocular trauma and history of ocular or periocular surgery were the cause of a significant number of cases of orbital cellulitis in our patients, compared with the studies of orbital cellulitis from Western countries.2,13,21,22 Less commonly reported causes of orbital cellulitis, such as dacryocystitis, dental infection, and endophthalmitis, also were found among our patients. As in studies from the West, a CT scan (axial and coronal) was the imaging study of choice for identification of sinusitis and orbital cellulitis as well as for confirmation of orbital or intracranial abscess in the vast majority of patients. Surgical intervention usually was required in cases of orbital cellulitis with compro-
mised optic nerve function or when orbital cellulitis failed to respond to medical management. The main purpose of surgery was to drain any purulent material, to relieve intracranial pressure, and to obtain adequate culture material for identification of causative organism, if any.22 Combined endoscopic sinus surgery with transnasal orbital abscess drainage reported in the studies from Western countries23 also was proven to be effective in the treatment of orbital cellulitis with orbital abscess with compromised visual function or after failed medical management in some of our patients. The present study supports findings from previous studies in which a CT scan was indicated in all patients with periorbital inflammation in whom proptosis, ophthalmoplegia, or a decrease in visual acuity developed; in whom a foreign body or an abscess was suspected; in whom severe eyelid edema prevented an adequate examination, when neurological signs were present, to rule out associated epidural or subdural empyema, brain abscess, or cavernous sinus thrombosis; or in whom surgery was contemplated.13,21,24,25 Repeat CT scans were helpful in patients in whom orbital inflammation progressed despite initial treatment with broad-spectrum antibiotics to assess resolution of infection or development of new abscess. Orbital cellulitis has been reported after orbital fractures in the setting of preexisting sinusitis.4,26 In the present study, 9 of the patients with orbital cellulitis were found to have evidence of preexisting sinusitis, and in 1 of these patients, delayed intervention resulted in total loss of vision. It has been postulated that in cases of preexisting sinusitis, microorganisms from adjacent infected sinuses enter the orbital cavity via the fracture and disrupt periorbita. The presence of blood clots in the sinuses and compromised blood supply to the trapped orbital fat in the fracture site may predispose such patients to orbital cellulitis. Ben Simon et al22 reported 4 patients with orbital cellulitis identified after sustaining an orbital fracture in the setting of coexistent paranasal
Loss of Vision Resulting from Orbital Cellulitis Imaging
Antibiotics
Pathogen
Comment
Pansinusitis, SPA (superior nasal) Ceftazime, cefazoline
14 mos
Prior outside treatment, RAPD
Lacrimal sac & orbital abscess Pansinusitis, SPA (inferior & medial) Ethmoiditis, SPA to cavernous sinus Orbital mass
18 mos 11 mos
Acute dacryocystitis developed RAPD, exent
9 yrs
Oral steroids for 7 days, exent
8 yrs
Blood culture showed Staphylococcus epidermidis, exent Duration of pansinusitis not known
Pansinusitis, SPA (inferior & superior, orbital fracture) SPA (inferior) Cavernous thrombus, ethmoid/ sphenoiditis Pansinusitis, SPA (medial)
Staphylococcus aureus, Streptococcus agalactiae Gentamicin, flucloxacillin Staphylococcus aureus, Bacillus Penicillin G, flucloxacillin, Fungus, Basidiobolus venarum metronidazole Amphotericin B, Rhizopus species, mucormycosis gentamicin, cefazoline NR Rhabdomylosis, Conidiobolus inconagaus Gentamicin, cefazoline Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus epidermidis Gentamicin, cefazoline Gemella species, Peptostreptococcus asaccharolyticus Amikacin, flucloxacillin NR
Length of Follow-up
Systemic antibiotics
NR
1 yr 15 mos
RAPD, CRAO
NR
CRAO/CRVO, transfer to a general hospital Abscess drained by FESS
8 mos
diabetes mellitus; EOM ⫽ extraocular movement; F ⫽ female; FESS ⫽ functional endoscopic sinus surgery; HTN ⫽ hypertension; IDDM ⫽ subperiosteal abscess; VA ⫽ visual acuity.
349
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Chaudhry et al 䡠 Outcome of Treated Orbital Cellulitis
Figure 7. A, B, Preoperative photographs of a 17-year-old boy who underwent drainage of his left orbital abscess and surgical treatment of his pansinusitis. C, D, Computed tomographic scans obtained 2 months later, when the patient sought treatment for left orbital abscess and pansinusitis requiring repeat abscess drainage and surgical treatment of his pansinusitis.
sinusitis. Although the use of prophylactic antibiotics after an orbital fracture has been controversial, their use in the setting of preexisting sinusitis has not been studied and may need further investigation.
As compared with one of the recent comprehensive studies of orbital cellulitis from Western countries in which orbital abscesses were found in 29% of patients with orbital cellulitis,2 orbital abscesses were identified in more than
4™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™ Figure 2. A, Photograph of a 6-year-old child with a history of trauma who had granulation tissue over the superior aspect of the right medial canthal area, right proptosis, and painful eye movements at presentation. Computed tomographic scans, (B) sagittal and (C) coronal, revealing a highly reflective intraorbital foreign body. D, Photograph showing exploration of the wound through the entry of a foreign body revealed a piece of a pencil. Figure 3. A 27-year-old woman with a history of sinusitis experienced left orbital trauma after falling against a table edge. A, Photograph of the patient at presentation, 7 days after trauma. The patient had proptosis, pain, ophthalmoplegia, and decreased vision. Computed tomographic scans, (B) sagittal and (C) coronal, showing evidence of a large left orbital floor fracture and pansinusitis. D, Photograph of the patient obtained 7 days after initial presentation. She showed improvement in her proptosis and extraocular motility, but her visual acuity remained at no light perception. Figure 4. A, Photograph of a 65-year-old woman with diabetes who had right-sided proptosis, loss of vision, and ophthalmoplegia at presentation. She was found to have evidence of fungal orbital cellulitis (B) and central retinal artery occlusion (C). The patient required exenteration and extended systemic antifungal therapy. Figure 5. A, Photograph of a 49-year-old man with a history of retinal detachment surgery who sought treatment for gradual proptosis in his right eye, ophthalmoplegia, and pain. B, C, Intraoperative photographs: the patient was found to have orbital cellulitis resulting from a scleral buckle that required removal. D, Photograph showing that the patient’s orbital cellulitis improved after surgery and administration of systemic antibiotics. Figure 6. A, Photograph of a 25-day-old girl who was found to have gradual proptosis of both of her eyes several days after birth. Imaging studies, (B) axial computed tomographic scan, (C) magnetic resonance imaging (MRI) scan axial, and (D) coronal MRI scan, demonstrating bilateral orbital and right subdural parietal abscesses. E, F, Intraoperative photographs demonstrating that right orbital abscesses were drained, which revealed methicillin-resistant Staphylococcus aureus that required 6 weeks of systemic vancomycin therapy. G, Photograph of the patient 2 months after initial presentation showing complete resolution of orbital and subdural abscesses.
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Ophthalmology Volume 114, Number 2, February 2007 half of the patients with orbital cellulitis at presentation in the present study. Delay in seeking treatment at a health care facility, diagnosis, and timely intervention were the cause of orbital abscess formation in more than half of our patients with orbital cellulitis. However, the development of an orbital abscess did not correlate specifically with visual acuity, proptosis, chemosis, or any other sign. In the present study among the patients in whom blood cultures were studied, only 4 patients had positive blood culture results in the setting of their orbital cellulitis, and 3 of these patients were children. Positive blood culture results have been found in 5% of adults and 33% of children younger than 4 years with orbital cellulitis.27 However, in one study of 50 patients with orbital cellulitis, none of the blood culture results were positive.2 It is possible that partial antibiotic treatment in some of these patients may have prevented growth of the affecting organism.21 In our study, 91% of the orbital abscesses drained had evidence of microbial growth at the time of surgery. Lack of microbial growth in up to 25% of drained orbital abscesses in Western countries could be the result of administering systemic antibiotics to these patients before they underwent drainage.13 This apparent difference could be the result of the lack of widespread use of antibiotics for common sinusitis in patients referred to a tertiary care center in the Middle East. The bacteriology of orbital abscesses has received little attention. In a series in which the contents of the abscess cavity were cultured, a wide range of organisms were recovered; among them were Staphylococci and Streptococci species, in addition to H. influenzae, Escherichia coli, and diphtheroids. In our study, the most common bacteria cultured from abscesses of the orbit included Staphylococci and Streptococci species, in addition to other multiple species of aerobes and anaerobes, which was similar to the results of previous studies from Western countries.13,19 Schramm et al19 reported 32 cases of orbital abscess in which the disease-causing microorganisms were reported to be predominantly Staphylococci and Streptococci species. The role of anaerobes, not usually considered pathogens in sinus disease, is unclear, although as in previous studies, a considerable number of our cultures in adults yielded anaerobes, stressing the need for broad-spectrum antibiotics until culture results become available. The frequency of orbital complications from orbital cellulitis ranges from as low of 0.5% to 3.9% to as high as 39%.2,13 Differences among these studies may be the result of their inclusion criteria, age group, and the severity of the complications studied. For example, in Western countries in the preantibiotic era, orbital cellulitis resulted in blindness in up to 20% of patients; a significant number of patients faced death.28 In the antibiotic era, it is reported that approximately 10% of patients with orbital complications of sinusitis have a temporary loss of vision that resolves within 2 to 6 weeks.19 However, from a survey of 46 patients with a confirmed diagnosis of orbital cellulitis associated with orbital abscess in which visual results were recorded, permanent monocular blindness developed in 7 patients (15%).29 Complications of sinusitis have been drastically reduced in recent years because of the widespread use of antibiotics to treat cases of upper respiratory tract infection
352
in Western countries.14 In 4 of the patients in the present study whose visual acuity remained at no light perception despite aggressive systemic antibiotic treatment and drainage of their paranasal and orbital abscesses, their disease was the result of untreated sinusitis. Most patients with refractory or complicated orbital abscesses have been older children or adults. Among 159 patients with orbital complications of sinusitis, 4 had permanent loss of vision30; all 4 had surgically confirmed orbital abscesses and all 4 were 15 years of age or older. El-Sayed and Al-Muhaimeid31 reported 2 patients with acute visual loss as a complication of orbital cellulitis resulting from sinusitis. In 1 patient, dramatic improvement in vision (from hand movements to normal) resulted from intravenous treatment of pansinusitis and associated orbital cellulitis. In the second patient (a 10-year-old girl), visual acuity returned from no light perception to normal after exploration of the sphenoid and ethmoid sinuses and treatment with intravenous antibiotics. Slavin and Glaser29 described 3 cases of sphenoethmoiditis causing irreversible visual loss associated with minimal signs of orbital inflammation and renamed the entity posterior orbital cellulitis. They defined it as a clinical syndrome in which early severe visual loss overshadows or precedes accompanying orbital inflammatory signs. Blindness also can result from orbital infarction syndrome. The blindness and retinal and optic nerve damage can be permanent.32 Our study demonstrates that visual loss in the setting of orbital cellulitis and abscess formation is possible. It is mandatory that appropriate antibiotic therapy be instituted and, when indicated, surgical intervention be carried out in a timely fashion. Orbital CT scans should be obtained when the diagnosis of orbital abscess is in question. Delayed initial diagnosis and late surgical intervention where indicated were most likely to produce poor visual results in our study. Delay in correct diagnosis and surgical intervention also were the 2 main reason for poor visual outcome in some of the previously reported studies.13,29,30 Hornblass et al13 reviewed 148 patients with orbital abscesses and found 3 patients with no light perception visual acuity. In the series reported by Patt and Manning,30 4 of 38 patients with orbital cellulitis incurred permanent loss of vision, with 1 of these patients progressing to no light perception vision. The cause of visual loss in orbital cellulitis may include vascular compromise of the optic nerve or retina, compressive optic neuropathy, or inflammatory or infiltrative optic neuropathy. Vasculitis because of inflammatory or toxic factors (septic vasculitis) also may be a factor. The confinement of the optic nerve in the orbital apex and within its bony canal and its proximity to the posterior ethmoidal and sphenoidal sinuses magnify the importance of the causal factors in posterior orbital cellulitis. Visual loss may be the result of optic atrophy, central retinal artery occlusion, or exposure keratopathy with ulcer formation.14,19 Increased orbital pressure may lead to vascular insufficiency secondary to traction on the optic nerve and central retinal artery or may be the result of decreased orbital arterial and increased venous pressure. Irreversible visual loss in orbital cellulitis probably has a vascular cause, whereas patients with subtotal vi-
Chaudhry et al 䡠 Outcome of Treated Orbital Cellulitis sual loss who respond to antibiotic therapy and drainage procedures most likely have visual compromise that is the result of infiltrative or compressive optic neuropathy. Other hypothesized mechanisms of visual loss are septic optic neuritis; embolic or thrombotic lesions in the vascular supply to the retina, choroids, or optic nerve; or a rapid elevation of intraocular pressure.29,30 Although rare, intracranial abscess is a life-threatening complication of the orbital abscess. As with orbital abscess, successful management of supportive intracranial abscess requires early recognition of the disease process, intravenous antibiotics, serial neuroimaging, and early surgical management of sinus and orbital disease and often the intracranial disease. In the present study, magnetic resonance imaging with fat suppression at 2- to 3-mm cuts was useful for visualizing the intracranial component of abscess. Most intracranial supportive complications of sinusitis are polymicrobial, with anaerobes being the most common pathogens.15 No specific species or combination of organisms was found to be predominant; however, Staphylococci and Streptococci species were encountered more often. Each of the 3 patients in a study by Hartstein et al15 had polymicrobial infection with no predominance of organisms. Our results demonstrate that the risk of blindness with orbital cellulitis is very real in this era of antibiotic therapy, and surgical drainage is still the most definitive method of addressing the problem when the diagnosis is confirmed by CT scan or is suggested strongly by clinical and imaging studies. Like our colleagues in Western countries, physicians in developing countries must pay attention to the initial clinical presentation, the progression of orbital signs, and the overall health of the patient without any unnecessary delay. On the basis of our experience in dealing with total visual loss in 9 patients and partial visual loss in 4 patients as a result of orbital cellulitis, we agree with the previous recommendations of Patt and Manning30 for surgical exploration of orbits and sinuses in cases of (1) definite or CT scan evidence of orbital suppuration; (2) initial presentation of significantly decreased visual acuity with orbital cellulitis in an immunocompromised patient; (3) initial presentation of severe orbital compromise, such as blindness or afferent pupillary defect with ipsilateral cellulitis; and (4) any significant progression of orbital signs while receiving a regimen of intravenous antibiotics. We agree with their suggestion that the dreadful complication of visual loss can be avoided if sinusitis is diagnosed and treated early in the course of the disease. Meanwhile, early drainage of orbital abscesses rather than observation of the response to antibiotics therapy over several days is stressed by Harris25 to prevent development of blindness in adult patients. In conclusion, sinus disease and trauma were the 2 most common causes of orbital cellulitis in our study. The investigations of most use were by CT scan and ultrasonography of the orbits, which provided confirmation of orbital cellulitis and presence or absence of an abscess. Cultures taken from abscesses at the time of drainage were more likely to produce positive results, whereas routine blood cultures were not of much help. Treatment with empirical broad-
spectrum systemic antibiotics may be justifiable in most cases of orbital cellulitis, needing modification in those patients in whom proper identification of the organism is made or when the desired clinical response is not achieved. Visual complications resulting from orbital cellulitis referred to a tertiary eye care facility remain a major concern. Patients with orbital cellulitis and abscess who seek treatment late in the course of their disease may experience permanent visual loss. Clinicians should be aware that patients with orbital cellulitis are at risk for developing severe visual loss, and such patients should be treated promptly with systemic antibiotics and, when indicated, with abscess drainage surgery.
References 1. Connell B, Kamal Z, McNab AA. Fulminant orbital cellulitis with complete loss of vision. Clin Exp Ophthalmol 2001;29: 260 –1. 2. Ferguson MP, McNab AA. Current treatment and outcome in orbital cellulitis. Aust N Z J Ophthalmol 1999;27:375–9. 3. Garcia GH, Harris GJ. Criteria from nonsurgical management of subperiosteal abscess of the orbit: analysis of outcomes 1988 –1998. Ophthalmology 2000;107:1454 – 6, discussion 1457– 8. 4. Paterson AW, Barnard NA, Irvine GH. Naso-orbital fracture leading to orbital cellulitis, and visual loss as a complication of chronic sinusitis. Br J Oral Maxillofac Surg 1994;32:80 –2. 5. Muqit MM, Saidkasimova S, Gavin M. Acute orbital cellulitis after sub-Tenon’s eye block [letter]. Anesthesia 2004;59: 411–3. 6. Kumar V, Saunders D. Orbital cellulitis after phacoemulsification and intraocular lens implantation. J Cataract Refract Surg 2004;30:918 –20. 7. Allen MV, Cohen KL, Grimson BS. Orbital cellulitis secondary to dacryocystitis following blepharoplasty. Ann Ophthalmol 1985;17:498 –9. 8. Wilson ME, Paul TO. Orbital cellulitis following strabismus surgery. Ophthalmic Surg 1987;18:92– 4. 9. Irvine F, McNab AA. Orbital abscess following uncomplicated phacoemulsification cataract surgery. Clin Experiment Ophthalmol 2002;30:430 –1. 10. Oluwole M, White P. Orbital floor fracture following nose blowing. Ear Nose Throat J 1996;75:169 –70. 11. Bakshi R, Wright PD, Kinkel PR, et al. Cranial magnetic resonance imaging findings in bacterial endocarditis: the neuroimaging spectrum of septic brain embolization demonstrated in twelve patients. J Neuroimaging 1999;9:78 – 84. 12. Duke-Elder S, MacFaul PA. The ocular adnexa: part 2. Lacrimal orbital and para orbital diseases. In: Duke-Elder S, ed. System of Ophthalmology. Vol. 13. London: Henry Kimpton; 1974:859 – 89. 13. Hornblass A, Herschorn BJ, Stern K, Grimes C. Orbital abscess. Surv Ophthalmol 1984;29:169 –78. 14. Jarrett WH II, Gutman FA. Ocular complications of infection in the paranasal sinuses. Arch Ophthalmol 1969;81:683– 8. 15. Hartstein ME, Steinvurzel MD, Cohen CP. Intracranial abscess as a complication of subperiosteal abscess of the orbit. Ophthal Plast Reconstr Surg 2001;17:398 – 403. 16. Hodges E, Tabbara KF. Orbital cellulitis: review of 23 cases from Saudi Arabia. Br J Ophthalmol 1989;73:205– 8. 17. Wagoner MD, al-Rajhi AA. Ophthalmology in the Kingdom of Saudi Arabia. Arch Ophthalmol 2001;119:1539 – 43.
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Ophthalmology Volume 114, Number 2, February 2007 18. Mullaney PB, Karcioglu ZA, Huaman AM, a1-Mesfer S. Retinoblastoma associated orbital cellulitis. Br J Ophthalmol 1998;82:517–21. 19. Schramm VL, Meyers EN, Kennerdell JS. Orbital complications of acute sinusitis: evaluation, management, and outcome. Otolaryngology 1978;86:ORL221–30. 20. Fearon B, Edmonds B, Bird R. Orbital-facial complication of sinusitis in children. Laryngoscope 1979;89:947–53. 21. Harris GJ. Subperiosteal abscess of the orbit: age as a factor in the bacteriology and response to treatment. Ophthalmology 1994;101:585–95. 22. Ben Simon GJ, Bush S, Selva D, McNab AA. Orbital cellulitis: a rare complication after orbital blowout fracture. Ophthalmology 2005;112:2030 – 4. 23. Pelton RW, Smith ME, Patel BC, Kelly SM. Cosmetic considerations in surgery for orbital subperiosteal abscess in children: experience with a combined transcaruncular and transnasal endoscopic approach. Arch Otolaryngol Head Neck Surg 2003;129:652–5. 24. Harris GJ. Subperiosteal abscess of the orbit: computed tomography and the clinical course. Ophthal Plast Reconstr Surg 1996;12:1– 8.
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25. Harris GJ. Subperiosteal abscess of the orbit: older children and adults require aggressive treatment. Ophthal Plast Reconstr Surg 2001;17:395–7. 26. Dhariwal D, Kittur MA, Farrier JN, et al. Post-traumatic orbital cellulitis. Br J Oral Maxillofac Surg 2003;41: 21– 8. 27. Bhargava D, Sankhla D, Chand P. Undiagnosed sinusitis leading to orbital cellulitis. Hosp Med 2002;63:50 –1. 28. Chandler JR, Langenbrunner DJ, Stevens ER. The pathogenesis of orbital complications in acute sinusitis. Laryngoscope 1970;80:1414 –28. 29. Slavin ML, Glaser JS. Acute severe irreversible visual loss with sphenoethmoiditis—“posterior” orbital cellulitis. Arch Ophthalmol 1987;105:345– 8. 30. Patt BS, Manning SC. Blindness resulting from orbital complications of sinusitis. Otolaryngol Head Neck Surg 1991;104: 789 –95. 31. El-Sayed Y, Al-Muhaimeid H. Acute visual loss in association with sinusitis. J Laryngol Otol 1993;107:840 –2. 32. Borruat FX, Bogousslavsky J, Uffer S, et al. Orbital infarction syndrome. Ophthalmology 1993;100:562– 8.
Orbital cellulitis is a relatively uncommon infectious process previously associated with severe complications involving ocular adnexal structures posterior to the orbital septum.1 It is primarily a disease of children and young adults, with a peak incidence in the 0- to 15-year age group.2 The most common predisposing factor is sinus
disease, particularly in the younger age groups.1–3 Less common risk factors include periocular trauma, prior history of surgery, dacryocystitis, retained orbital foreign body, recent history of dental infection, endophthalmitis, bacterial endocarditis, and intraocular and orbital tumors.4 –11 In the past, orbital cellulitis has been associated
Originally received: May 17, 2006. Accepted: July 12, 2006.
5
Manuscript no. 2006-543.
1
Oculoplastic and Orbit Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia.
2
Research Department, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia.
3
Royal Eye Infirmary, New Castle-upon-Tyne, United Kingdom.
4
Department of Ophthalmology, King Saud University, Riyadh, Saudi Arabia.
© 2007 by the American Academy of Ophthalmology Published by Elsevier Inc.
Department of Ophthalmology, Baylor College of Medicine, Houston, Texas. Department of Ophthalmology, Wilford Hall Medical Center, San Antonio, Texas. Presented at: American Academy of Ophthalmology Annual Meeting, October 2005, Chicago, Illinois. The authors have no propriety interests related to the study. Correspondence to Imtiaz A. Chaudhry, MD, PhD, Oculoplastic and Orbit Division, King Khaled Eye Specialist Hospital, P.O. Box 7191, Riyadh 11462, Saudi Arabia. E-mail: [email protected].
6
ISSN 0161-6420/07/$–see front matter doi:10.1016/j.ophtha.2006.07.059
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Ophthalmology Volume 114, Number 2, February 2007 Table 1. Presenting Signs and Symptoms of Orbital Cellulitis Signs and Symptoms Swelling Proptosis Restricted motility Pain Decreased VA Ptosis Headache Diplopia RAPD
No. of Patients
Percentage
156 149 129 114 31 23 22 14 12
71.5 68.3 59.2 52.3 14.2 10.6 10.1 6.4 5.5
RAPD ⫽ relative afferent pupillary defect; VA ⫽ visual acuity.
cations of intracranial abscess have been found as a result of cavernous sinus thrombosis and intracranial rupture of the abscess.15 Most of the previous studies of orbital cellulitis have come from Western countries, and studies from developing countries have been reported rarely in the literature.16,17 The purpose of this study was to review the clinical records of patients referred to King Khaled Eye Specialist Hospital, an accredited (Joint Council on Accreditation of Healthcare Organizations, Washington, DC) tertiary eye care referral center in Riyadh, Saudi Arabia, with the diagnosis of orbital cellulitis to determine the predisposing risk factors and outcomes of treatment.
Patients and Methods with a number of serious complications, including loss of visual acuity, cavernous sinus thrombosis, meningitis, frontal abscess, osteomyelitis, and even death.12 Since the advent of effective antibiotic treatments, these serious complications have become much less frequent.13 From the past series in which final visual results have been reported, a significant percentage of patients were left with blind eyes, ranging anywhere from 7.1% to as high as 23.6%.14 Fatal compli-
After obtaining approval from the institutional review board, a retrospective review was made of the medical records of all patients admitted to the King Khaled Eye Specialist Hospital with a diagnosis of orbital cellulitis under the Diagnostic Related Group coding for the past 15 years. The search was performed in a computerized database of all patients with diagnosis of orbital cellulitis. The clinical charts were reviewed for patient demographics such as age, gender, and presence of the following clinical
Figure 1. A, Photograph of a 12-year-old girl with 2-week history of sinusitis and orbital cellulitis at initial presentation. B, Photograph obtained 48 hours after beginning intravenous antibiotics showing that the patient’s left-sided orbital cellulitis worsened with increased proptosis, chemosis, and ophthalmoplegia. C, Repeat computed tomographic scan revealing an increase in left orbital abscess requiring urgent drainage. D, Photograph of the same patient 2 days after drainage of left orbital abscess.
346
Chaudhry et al 䡠 Outcome of Treated Orbital Cellulitis Table 2. Causes of Orbital Cellulitis (n ⫽ 214) Location
No. of Patients
Percentage
Sinusitis Trauma Endophthalmitis Orbital implants Dacryocystitis Dental infection Retained foreign body Scleral buckle Sinusitis and trauma Tumors* Others†
86 43 29 18 10 6 7 5 9 8 11
39.4 19.7 13.3 8.2 4.6 2.7 3.2 2.3 4.1 3.7 5.1
*Retinoblastoma, n ⫽ 6; rhabdomyosarcoma, n ⫽ 1; melanoma, n ⫽ 1. † Exenterated sockets, n ⫽ 4; aqueous drainage devices, n ⫽ 2; insect bite, n ⫽ 1; topical neomycin drops, n ⫽ 2; strabismus surgery, n ⫽ 1; keratoprosthesis, n ⫽ 1.
features: external ophthalmoplegia, proptosis, chemosis, decreased visual acuity, and any radiologic evidence of orbital inflammation, sinusitis, and intracranial or orbital abscess. Only patients fulfilling the diagnostic criteria for orbital cellulitis, such as ophthalmoplegia, proptosis, chemosis, decreased visual acuity, or radiologic evidence of orbital inflammation or abscess, were included in the study. Predisposing factors such as sinusitis, previous history of trauma, surgery, dacryocystitis, or dental abscess were investigated. Information regarding the use of systemic (oral or intravenous) antibiotics before admission, during admission, and at discharge was gathered. Snellen visual acuity as well as ocular examination of these patients were reviewed from first presentation and the last follow-up examination, either at the time of discharge or as outpatient, where recorded. Operative notes were reviewed regarding the procedure performed in those patients where orbital abscesses were drained. Patients in whom no surgical intervention was performed and who improved were identified on the basis of clinical and imaging studies, including resolution of orbital abscess. The microbiology results were studied for the growth of microorganisms from the surgically drained abscesses where cultures were performed. In cases where the microorganisms were identified from abscess cultures, the organisms were investigated and cases of mixed aerobes and anaerobes identified. Patients with any visual impairment resulting from orbital cellulitis were identified before and after completion of treatment, and their risk factors were studied. Complications after resolution of orbital cellulitis were noted either on discharge or at last outpatient follow-up. In particular, complications such as reduction in Snellen visual acuity, repeat infection, intracranial extension, loss of ocular motility, and persistent ptosis were noted. Table 3. Surgeries Performed (n ⫽ 159 Orbits)
Table 4. The Most Common Microorganisms Isolated from Orbital Abscess (n ⫽ 91) Percentage Microorganism Isolated
No. of Isolates Overall Within Group
Gram positive Staphylococcus aureus Staphylococcus epidermidis Streptococcus pneumoniae Streptococcus viridans Streptococcus pyogenes -hemolytic streptococcus A Other Streptococci species Gram negative Haemophilus influenza Pseudomonas species Escherichia coli Eikenella species Actinobacter species Corynebacterium species Morexella species Enterobacter species Others Anaerobes Propionibacterium acnes Peptostreptococcus species Veillonella species Fungi
23 18 9 7 4 4 11
16.7 13.1 6.5 5 3 3 8
30.2 23.6 11.8 9.2 5.2 5.2 14.5
6 4 4 3 1 2 2 2 4
4.3 3 3 2.1 ⬍1 1.5 1.5 1.5 3
21.4 14.3 14.3 10.7 3.5 7 7 7 14.3
11 1 1 8
12 ⬍1 ⬍1 8.8
84.6 7.7 7.7 NA
NA ⫽ not applicable.
Results A total of 218 patients (136 male, 82 female; 4 bilateral) fulfilling the diagnostic criteria for orbital cellulitis were identified. The average age of these patients was 25.7 years (range, 1 month– 85 years). In total, 114 patients (52%) were younger than 16 years of age. The right side was involved in 110 orbits (50.5%), and the left was involved in 108 orbits (49.5%). Presenting signs included eyelid swelling in 156 (71.5%), proptosis in 149 (68.3%), motility restriction in 129 (59.2%), pain in 114 (52.3%), and decreased visual acuity in 31 (14.2%) cases (Table 1). Diagnosis was made clinically and was confirmed by computed tomography (CT) scans or ultrasonography in 197 (90.4%) and 79 (36.2%) orbits, respectively. Orbital abscesses (Fig 1) were identified in 116 (53.2%) orbits. In all cases of orbital cellulitis, there was evidence of inflammatory or infective changes to orbital structures. Abscess location was found to be medial in 40 orbits (35%), superior in 38 orbits (33%), intraconal in 15 orbits (13%), superomedial in 7 orbits (6%), inferomedial in 7 orbits (6%), lateral in 2 orbits (1.7%), and unspecified in Table 5. Visual Acuity of Patients Treated for Orbital Cellulitis*
Procedure
No. of Patients
Percentage
Abscess drainage* Evisceration Enucleation Implant removal Exenteration† Dacryocystorhinostomy
101 21 18 6 7 6
46.3 9.6 8.2 2.7 3.2 2.7
*Fifteen abscesses not drained; culture positive from 91 specimens. † Orbital exenteration performed for fungal infection in 6 patients and for Wegener’s granuloma in 1 patient.
Snellen Visual Acuity 20/20–20/40 20/60–20/100 20/200–20/400 CF–LP Not taken
Initial Visual Acuity
Final Visual Acuity
63 23 4 12 14
88 5 3 7 1
CF ⫽ counting fingers; LP ⫽ light perception. *Not included were pediatric visual acuity and patients with orbital cellulitis secondary to endophthalmitis.
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Ophthalmology Volume 114, Number 2, February 2007 Table 6. Complications of Orbital Cellulitis (n ⫽ 218) Complication
No. of Patients
Percentage
Vision loss* Intracranial abscess extension Repeat infection Infected implant removal† Strabismus Persistent ptosis‡
13 9 9 6 6 4
6 4.1 4.1 2.7 2.7 1.8
*Includes complete loss of vision in 9 eyes, residual visual field defects in 2 eyes, and decreased visual acuity in 2 eyes resulting from corneal scar from exposure keratopathy. † Implants not exposed. ‡ Ptosis persisted more than 7 months after treatment of orbital cellulitis.
7 orbits (6%). In addition to orbital involvement, intracranial abscess was found in 9 patients (7.7%). Sinus disease was the most common predisposing cause in 86 patients (39.4%), trauma in 43 patients (19.7%), endophthalmitis in 29 patients (13.3%), orbital implants in 18 patients (8.2%), dacryocystitis in 10 patients (4.6%), retained orbital foreign body in 7 patients (3.2%; Fig 2), dental infection in 6 patients (2.7%), and scleral buckle in 5 patients (2.3%; Table 2). A history of sinusitis and recent trauma was the cause of orbital cellulitis in 9 patients (4.1%; Fig 3), and intraocular or orbital tumors were the cause in 8 patients (3.7%; 6 retinoblastomas, 1 rhabdomyosarcoma, and 1 melanoma) with orbital cellulitis.18 Less common were 11 patients (5%) who accounted for 4 exenterated orbital sockets, 2 orbits with previously implanted aqueous drainage devices, allergic reaction to topical neomycin drops in 2 orbits, recent strabismus surgery in 1 patient, keratoprosthesis in 1 patient, and a recent history of insect bite in another patient. All patients received systemic antibiotic treatment, and in all patients, treatment regimens were empirically based and were instituted before the identification of any responsible organisms. The most common antibiotic regimen included cephalosporins in 196 patients (90%), and aminoglycosides in 144 patients (66%) with a combination of other antibiotics. These antibiotics included flucloxacillin in 32 patients (15%), vancomycin in 29 patients
(13%), ampicillin in 13 patients (6%), metronidazole in 8 patients (4%), and penicillin in 6 patients (3%). Among the 116 radiologically confirmed orbital abscesses, 101 (87%) required drainage, and the remaining 15 (13%) were observed closely until their resolution while those patients were treated with systemic antibiotics. Thirty-nine eyes (17.8%) had endophthalmitis causing orbital cellulitis and required evisceration (21 [9.6%]) or enucleation (18 [8.2%]). Seven orbits (3.2%) required exenteration (Fig 4) and 6 (2.7%) infected orbital implants had to be removed (Fig 5). Six patients (2.7%) had dacryocystitis that required a dacryocystorhinostomy to treat orbital cellulitis in addition to the systemic antibiotics (Table 3). Combined endoscopic sinus surgery with transnasal orbital abscess drainage was carried out in some of our patients with sinusitis and orbital abscess, especially in the medial orbit. Cultures were performed in all patients in whom an orbital abscess was drained, and results were positive in 91 patients (90%). The most common microorganisms isolated from the drained abscesses were Staphylococci and Streptococci species; less common organisms included Propionibacterium acnes, Haemophilus influenzae, Bacillus, and fungi (Table 4). In addition to CT scans, magnetic resonance imaging studies with fat suppression at 2- to 3-mm cuts were useful for visualizing the intracranial component of abscess in addition to suspected orbital abscess. No specific species or combination of organisms was found to predominate; however, Staphylococci and Streptococci species were encountered more often. Blood cultures were positive in only 4 of 50 patients from whom blood was drawn for cultures. Thirteen patients (6.2%) required changes in their systemic antibiotics based on culture results or on no response to the initial antibiotics. Visual acuity improved in 34 eyes (16.1%) and worsened in 13 eyes (6.2%), including 9 eyes (4.3%) that sustained complete loss of vision (Tables 5, 6). The permanent loss of vision was attributed to the delay in diagnosis and intervention (Table 7). There were 9 cases of intracranial extension of orbital abscesses that required either extended treatment with systemic antibiotics alone or in combination with neurosurgical intervention (Fig 6). The average hospital stay was 8.9 days (range, 1–28 days). Most patients received oral antibiotics on discharge for varying periods, ranging from 3 days to 3 weeks. Repeat orbital cellulitis was found in 9 patients (4.1%; Fig 7). Table 7. Characteristics of Patients with Complete
Patient No.
Age (yrs)
Gender
Eye
1
60
M
R
Sinusitis
Decreased VA, pain, proptosis, decreased EOM
2 3
36 20
F F
L R
Chronic dacryocystitis Dental infection
Decreased VA, proptosis, decreased EOM Decreased VA, proptosis, decreased EOM
4
65
F
R
CE/IOL, IDDM
Decreased VA, pain, proptosis, decreased EOM
7 days
5
9
M
L
Trauma, R/O, rhabdomyosarcoma
Pain, proptosis, decreased EOM
1 mo
6
27
F
L
Sinusitis, trauma
Decreased VA, pain, proptosis
7 days after trauma
7
75
F
R
Sinusitis, DM, HTN
Decreased VA, pain, decreased EOM
25 days
8
30
M
L
Chickenpox
Decreased VA, pain, proptosis, decreased EOM
14 days
9
51
M
R
Sinusitis, DM, HTN
Decreased VA, proptosis
10 days
History
Symptoms
Duration 4 mos 14 days 1 mo
CE/IOL ⫽ cataract extraction/intraocular lens implantation; CRAO/CRVO ⫽ central retinal artery occlusion/central retinal vein occlusion; DM ⫽ insulin-dependent diabetes mellitus; L ⫽ left; M ⫽ male; NR ⫽ not reported; R ⫽ right; RAPD ⫽ relative afferent pupillary defect; R/O ⫽ rule out; SPA ⫽
348
Chaudhry et al 䡠 Outcome of Treated Orbital Cellulitis There were 6 cases of strabismus and 4 cases of ptosis that persisted more than 7 months after the treatment of orbital cellulitis. The average follow-up of these patients was 19 months (range, 1 week–12 years).
Discussion The results from this study confirm previous observations from Western countries in which sinus infection has been implicated as the cause of orbital cellulitis in most of the reported cases.13,19,20 Particularly in the pediatric population, up to 90% of patients with orbital cellulitis have existing sinusitis, with almost half having multiple sinus involvement.2 Unlike patients in Western countries, most patients with sinusitis and orbital cellulitis sought treatment later in the course of their disease in our study. The health care system in the Kingdom of Saudi Arabia has a 3-step referral process, with primary care physicians initially screening the patients. King Khaled Eye Specialist Hospital in Riyadh, the only major eye care hospital in the country, provides tertiary orbital care for most of the population of Saudi Arabia.17 Therefore, this study of 218 patients with orbital cellulitis over a 15-year period represents most of the patients who were referred to a tertiary eye care center. After sinusitis, periocular trauma and history of ocular or periocular surgery were the cause of a significant number of cases of orbital cellulitis in our patients, compared with the studies of orbital cellulitis from Western countries.2,13,21,22 Less commonly reported causes of orbital cellulitis, such as dacryocystitis, dental infection, and endophthalmitis, also were found among our patients. As in studies from the West, a CT scan (axial and coronal) was the imaging study of choice for identification of sinusitis and orbital cellulitis as well as for confirmation of orbital or intracranial abscess in the vast majority of patients. Surgical intervention usually was required in cases of orbital cellulitis with compro-
mised optic nerve function or when orbital cellulitis failed to respond to medical management. The main purpose of surgery was to drain any purulent material, to relieve intracranial pressure, and to obtain adequate culture material for identification of causative organism, if any.22 Combined endoscopic sinus surgery with transnasal orbital abscess drainage reported in the studies from Western countries23 also was proven to be effective in the treatment of orbital cellulitis with orbital abscess with compromised visual function or after failed medical management in some of our patients. The present study supports findings from previous studies in which a CT scan was indicated in all patients with periorbital inflammation in whom proptosis, ophthalmoplegia, or a decrease in visual acuity developed; in whom a foreign body or an abscess was suspected; in whom severe eyelid edema prevented an adequate examination, when neurological signs were present, to rule out associated epidural or subdural empyema, brain abscess, or cavernous sinus thrombosis; or in whom surgery was contemplated.13,21,24,25 Repeat CT scans were helpful in patients in whom orbital inflammation progressed despite initial treatment with broad-spectrum antibiotics to assess resolution of infection or development of new abscess. Orbital cellulitis has been reported after orbital fractures in the setting of preexisting sinusitis.4,26 In the present study, 9 of the patients with orbital cellulitis were found to have evidence of preexisting sinusitis, and in 1 of these patients, delayed intervention resulted in total loss of vision. It has been postulated that in cases of preexisting sinusitis, microorganisms from adjacent infected sinuses enter the orbital cavity via the fracture and disrupt periorbita. The presence of blood clots in the sinuses and compromised blood supply to the trapped orbital fat in the fracture site may predispose such patients to orbital cellulitis. Ben Simon et al22 reported 4 patients with orbital cellulitis identified after sustaining an orbital fracture in the setting of coexistent paranasal
Loss of Vision Resulting from Orbital Cellulitis Imaging
Antibiotics
Pathogen
Comment
Pansinusitis, SPA (superior nasal) Ceftazime, cefazoline
14 mos
Prior outside treatment, RAPD
Lacrimal sac & orbital abscess Pansinusitis, SPA (inferior & medial) Ethmoiditis, SPA to cavernous sinus Orbital mass
18 mos 11 mos
Acute dacryocystitis developed RAPD, exent
9 yrs
Oral steroids for 7 days, exent
8 yrs
Blood culture showed Staphylococcus epidermidis, exent Duration of pansinusitis not known
Pansinusitis, SPA (inferior & superior, orbital fracture) SPA (inferior) Cavernous thrombus, ethmoid/ sphenoiditis Pansinusitis, SPA (medial)
Staphylococcus aureus, Streptococcus agalactiae Gentamicin, flucloxacillin Staphylococcus aureus, Bacillus Penicillin G, flucloxacillin, Fungus, Basidiobolus venarum metronidazole Amphotericin B, Rhizopus species, mucormycosis gentamicin, cefazoline NR Rhabdomylosis, Conidiobolus inconagaus Gentamicin, cefazoline Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus epidermidis Gentamicin, cefazoline Gemella species, Peptostreptococcus asaccharolyticus Amikacin, flucloxacillin NR
Length of Follow-up
Systemic antibiotics
NR
1 yr 15 mos
RAPD, CRAO
NR
CRAO/CRVO, transfer to a general hospital Abscess drained by FESS
8 mos
diabetes mellitus; EOM ⫽ extraocular movement; F ⫽ female; FESS ⫽ functional endoscopic sinus surgery; HTN ⫽ hypertension; IDDM ⫽ subperiosteal abscess; VA ⫽ visual acuity.
349
350
Chaudhry et al 䡠 Outcome of Treated Orbital Cellulitis
Figure 7. A, B, Preoperative photographs of a 17-year-old boy who underwent drainage of his left orbital abscess and surgical treatment of his pansinusitis. C, D, Computed tomographic scans obtained 2 months later, when the patient sought treatment for left orbital abscess and pansinusitis requiring repeat abscess drainage and surgical treatment of his pansinusitis.
sinusitis. Although the use of prophylactic antibiotics after an orbital fracture has been controversial, their use in the setting of preexisting sinusitis has not been studied and may need further investigation.
As compared with one of the recent comprehensive studies of orbital cellulitis from Western countries in which orbital abscesses were found in 29% of patients with orbital cellulitis,2 orbital abscesses were identified in more than
4™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™ Figure 2. A, Photograph of a 6-year-old child with a history of trauma who had granulation tissue over the superior aspect of the right medial canthal area, right proptosis, and painful eye movements at presentation. Computed tomographic scans, (B) sagittal and (C) coronal, revealing a highly reflective intraorbital foreign body. D, Photograph showing exploration of the wound through the entry of a foreign body revealed a piece of a pencil. Figure 3. A 27-year-old woman with a history of sinusitis experienced left orbital trauma after falling against a table edge. A, Photograph of the patient at presentation, 7 days after trauma. The patient had proptosis, pain, ophthalmoplegia, and decreased vision. Computed tomographic scans, (B) sagittal and (C) coronal, showing evidence of a large left orbital floor fracture and pansinusitis. D, Photograph of the patient obtained 7 days after initial presentation. She showed improvement in her proptosis and extraocular motility, but her visual acuity remained at no light perception. Figure 4. A, Photograph of a 65-year-old woman with diabetes who had right-sided proptosis, loss of vision, and ophthalmoplegia at presentation. She was found to have evidence of fungal orbital cellulitis (B) and central retinal artery occlusion (C). The patient required exenteration and extended systemic antifungal therapy. Figure 5. A, Photograph of a 49-year-old man with a history of retinal detachment surgery who sought treatment for gradual proptosis in his right eye, ophthalmoplegia, and pain. B, C, Intraoperative photographs: the patient was found to have orbital cellulitis resulting from a scleral buckle that required removal. D, Photograph showing that the patient’s orbital cellulitis improved after surgery and administration of systemic antibiotics. Figure 6. A, Photograph of a 25-day-old girl who was found to have gradual proptosis of both of her eyes several days after birth. Imaging studies, (B) axial computed tomographic scan, (C) magnetic resonance imaging (MRI) scan axial, and (D) coronal MRI scan, demonstrating bilateral orbital and right subdural parietal abscesses. E, F, Intraoperative photographs demonstrating that right orbital abscesses were drained, which revealed methicillin-resistant Staphylococcus aureus that required 6 weeks of systemic vancomycin therapy. G, Photograph of the patient 2 months after initial presentation showing complete resolution of orbital and subdural abscesses.
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Ophthalmology Volume 114, Number 2, February 2007 half of the patients with orbital cellulitis at presentation in the present study. Delay in seeking treatment at a health care facility, diagnosis, and timely intervention were the cause of orbital abscess formation in more than half of our patients with orbital cellulitis. However, the development of an orbital abscess did not correlate specifically with visual acuity, proptosis, chemosis, or any other sign. In the present study among the patients in whom blood cultures were studied, only 4 patients had positive blood culture results in the setting of their orbital cellulitis, and 3 of these patients were children. Positive blood culture results have been found in 5% of adults and 33% of children younger than 4 years with orbital cellulitis.27 However, in one study of 50 patients with orbital cellulitis, none of the blood culture results were positive.2 It is possible that partial antibiotic treatment in some of these patients may have prevented growth of the affecting organism.21 In our study, 91% of the orbital abscesses drained had evidence of microbial growth at the time of surgery. Lack of microbial growth in up to 25% of drained orbital abscesses in Western countries could be the result of administering systemic antibiotics to these patients before they underwent drainage.13 This apparent difference could be the result of the lack of widespread use of antibiotics for common sinusitis in patients referred to a tertiary care center in the Middle East. The bacteriology of orbital abscesses has received little attention. In a series in which the contents of the abscess cavity were cultured, a wide range of organisms were recovered; among them were Staphylococci and Streptococci species, in addition to H. influenzae, Escherichia coli, and diphtheroids. In our study, the most common bacteria cultured from abscesses of the orbit included Staphylococci and Streptococci species, in addition to other multiple species of aerobes and anaerobes, which was similar to the results of previous studies from Western countries.13,19 Schramm et al19 reported 32 cases of orbital abscess in which the disease-causing microorganisms were reported to be predominantly Staphylococci and Streptococci species. The role of anaerobes, not usually considered pathogens in sinus disease, is unclear, although as in previous studies, a considerable number of our cultures in adults yielded anaerobes, stressing the need for broad-spectrum antibiotics until culture results become available. The frequency of orbital complications from orbital cellulitis ranges from as low of 0.5% to 3.9% to as high as 39%.2,13 Differences among these studies may be the result of their inclusion criteria, age group, and the severity of the complications studied. For example, in Western countries in the preantibiotic era, orbital cellulitis resulted in blindness in up to 20% of patients; a significant number of patients faced death.28 In the antibiotic era, it is reported that approximately 10% of patients with orbital complications of sinusitis have a temporary loss of vision that resolves within 2 to 6 weeks.19 However, from a survey of 46 patients with a confirmed diagnosis of orbital cellulitis associated with orbital abscess in which visual results were recorded, permanent monocular blindness developed in 7 patients (15%).29 Complications of sinusitis have been drastically reduced in recent years because of the widespread use of antibiotics to treat cases of upper respiratory tract infection
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in Western countries.14 In 4 of the patients in the present study whose visual acuity remained at no light perception despite aggressive systemic antibiotic treatment and drainage of their paranasal and orbital abscesses, their disease was the result of untreated sinusitis. Most patients with refractory or complicated orbital abscesses have been older children or adults. Among 159 patients with orbital complications of sinusitis, 4 had permanent loss of vision30; all 4 had surgically confirmed orbital abscesses and all 4 were 15 years of age or older. El-Sayed and Al-Muhaimeid31 reported 2 patients with acute visual loss as a complication of orbital cellulitis resulting from sinusitis. In 1 patient, dramatic improvement in vision (from hand movements to normal) resulted from intravenous treatment of pansinusitis and associated orbital cellulitis. In the second patient (a 10-year-old girl), visual acuity returned from no light perception to normal after exploration of the sphenoid and ethmoid sinuses and treatment with intravenous antibiotics. Slavin and Glaser29 described 3 cases of sphenoethmoiditis causing irreversible visual loss associated with minimal signs of orbital inflammation and renamed the entity posterior orbital cellulitis. They defined it as a clinical syndrome in which early severe visual loss overshadows or precedes accompanying orbital inflammatory signs. Blindness also can result from orbital infarction syndrome. The blindness and retinal and optic nerve damage can be permanent.32 Our study demonstrates that visual loss in the setting of orbital cellulitis and abscess formation is possible. It is mandatory that appropriate antibiotic therapy be instituted and, when indicated, surgical intervention be carried out in a timely fashion. Orbital CT scans should be obtained when the diagnosis of orbital abscess is in question. Delayed initial diagnosis and late surgical intervention where indicated were most likely to produce poor visual results in our study. Delay in correct diagnosis and surgical intervention also were the 2 main reason for poor visual outcome in some of the previously reported studies.13,29,30 Hornblass et al13 reviewed 148 patients with orbital abscesses and found 3 patients with no light perception visual acuity. In the series reported by Patt and Manning,30 4 of 38 patients with orbital cellulitis incurred permanent loss of vision, with 1 of these patients progressing to no light perception vision. The cause of visual loss in orbital cellulitis may include vascular compromise of the optic nerve or retina, compressive optic neuropathy, or inflammatory or infiltrative optic neuropathy. Vasculitis because of inflammatory or toxic factors (septic vasculitis) also may be a factor. The confinement of the optic nerve in the orbital apex and within its bony canal and its proximity to the posterior ethmoidal and sphenoidal sinuses magnify the importance of the causal factors in posterior orbital cellulitis. Visual loss may be the result of optic atrophy, central retinal artery occlusion, or exposure keratopathy with ulcer formation.14,19 Increased orbital pressure may lead to vascular insufficiency secondary to traction on the optic nerve and central retinal artery or may be the result of decreased orbital arterial and increased venous pressure. Irreversible visual loss in orbital cellulitis probably has a vascular cause, whereas patients with subtotal vi-
Chaudhry et al 䡠 Outcome of Treated Orbital Cellulitis sual loss who respond to antibiotic therapy and drainage procedures most likely have visual compromise that is the result of infiltrative or compressive optic neuropathy. Other hypothesized mechanisms of visual loss are septic optic neuritis; embolic or thrombotic lesions in the vascular supply to the retina, choroids, or optic nerve; or a rapid elevation of intraocular pressure.29,30 Although rare, intracranial abscess is a life-threatening complication of the orbital abscess. As with orbital abscess, successful management of supportive intracranial abscess requires early recognition of the disease process, intravenous antibiotics, serial neuroimaging, and early surgical management of sinus and orbital disease and often the intracranial disease. In the present study, magnetic resonance imaging with fat suppression at 2- to 3-mm cuts was useful for visualizing the intracranial component of abscess. Most intracranial supportive complications of sinusitis are polymicrobial, with anaerobes being the most common pathogens.15 No specific species or combination of organisms was found to be predominant; however, Staphylococci and Streptococci species were encountered more often. Each of the 3 patients in a study by Hartstein et al15 had polymicrobial infection with no predominance of organisms. Our results demonstrate that the risk of blindness with orbital cellulitis is very real in this era of antibiotic therapy, and surgical drainage is still the most definitive method of addressing the problem when the diagnosis is confirmed by CT scan or is suggested strongly by clinical and imaging studies. Like our colleagues in Western countries, physicians in developing countries must pay attention to the initial clinical presentation, the progression of orbital signs, and the overall health of the patient without any unnecessary delay. On the basis of our experience in dealing with total visual loss in 9 patients and partial visual loss in 4 patients as a result of orbital cellulitis, we agree with the previous recommendations of Patt and Manning30 for surgical exploration of orbits and sinuses in cases of (1) definite or CT scan evidence of orbital suppuration; (2) initial presentation of significantly decreased visual acuity with orbital cellulitis in an immunocompromised patient; (3) initial presentation of severe orbital compromise, such as blindness or afferent pupillary defect with ipsilateral cellulitis; and (4) any significant progression of orbital signs while receiving a regimen of intravenous antibiotics. We agree with their suggestion that the dreadful complication of visual loss can be avoided if sinusitis is diagnosed and treated early in the course of the disease. Meanwhile, early drainage of orbital abscesses rather than observation of the response to antibiotics therapy over several days is stressed by Harris25 to prevent development of blindness in adult patients. In conclusion, sinus disease and trauma were the 2 most common causes of orbital cellulitis in our study. The investigations of most use were by CT scan and ultrasonography of the orbits, which provided confirmation of orbital cellulitis and presence or absence of an abscess. Cultures taken from abscesses at the time of drainage were more likely to produce positive results, whereas routine blood cultures were not of much help. Treatment with empirical broad-
spectrum systemic antibiotics may be justifiable in most cases of orbital cellulitis, needing modification in those patients in whom proper identification of the organism is made or when the desired clinical response is not achieved. Visual complications resulting from orbital cellulitis referred to a tertiary eye care facility remain a major concern. Patients with orbital cellulitis and abscess who seek treatment late in the course of their disease may experience permanent visual loss. Clinicians should be aware that patients with orbital cellulitis are at risk for developing severe visual loss, and such patients should be treated promptly with systemic antibiotics and, when indicated, with abscess drainage surgery.
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