Orbital Abscess—Two Case Reports with Review

A 35-year-old woman presented to the maxillofacial surgery department in Poznań due to massive eyelid swelling and severe pain in the left eye. Three days before the patient was admitted to the department, she was injured with a blunt instrument. The physical examination shows massive swelling of the eyelids of the left eye—closing the eyelid gap, exophthalmos of the left eyeball, severe pain on palpation, redness and warming of the surrounding soft tissues, eruptions on the skin of the upper and lower eyelids, body temperature 37.9 °C (Fig. 1). No other irregularities were found. Computed tomography of the orbital without contrast and an X-ray of the lungs, laboratory tests, electrocardiogram were ordered. Additional a smear was taken for bacteriological examination. The computed tomography image shows phlegmon of the left cheek and orbital (Fig. 2). In the ophthalmological examination, the right eye remained unchanged. In the left eye, there was an abscess of the eyelids and orbit, swelling of the eyeball and eyelid conjunctiva; transparent cornea; iris unchanged; the pupil is even, round and reacts correctly to light. The image of the fundus of the right eye was normal, the left eye was not available for examination. The patient was administered amoxicillin and clavulanic acid 1.2 g intravenous (IV) three times a day, Metronidazole 500 mg three times daily IV, ketoprofen 0.1 g twice daily, enoxaparin 0.4 ml once daily subcutaneous. Additionally, drops containing dexamethasone and tobramycin every two hours were used for the left eye. Under general endotracheal anaesthesia, an incision and drainage of the left orbital phlegmon were performed from the supraorbital and suborbital incisions, resulting in abundant purulent exudate (Fig. 3). The abscess cavity was rinsed with saline. A flow drain was introduced. In the postoperative period, the level of CRP and WBC was monitored—a decrease in CRP and WBC was observed. On the third day after surgery, a control ophthalmological examination confirmed correct vision in the left eye (Fig. 4). The microbiological examination revealed the alarm pathogen Streptococcus pyogenes susceptible to empirical therapy, Staphylococcus aureus, Staphylococcus epidermidis. The patient was discharged from the clinic on day 9 in good general condition. There were no visual disturbances in the left eye. The only permanent consequence was scarring of the facial skin after surgical access (Fig. 5).

A 63-year-old man was transferred from the department of ophthalmology to the department of maxillofacial surgery due to blindness in the left eye due to orbital phlegmon in order to decompress the abscess. 8 days before hospitalization, the patient suffered a facial injury as a result of hitting a metal gate. Immediately after the injury, the skin wound was treated at the ophthalmology department. Symptoms of acute inflammation appeared on the 5th day after the injury. Physical examination shows a contaminated, extensive wound to the skin of the upper eyelid and the left supraorbital area, penetrating the orbital along the roof and the sidewall, from which the exudate of the purulent content emerges. Left eye exophthalmos, the blindness of the left eye, significantly limited mobility of the left eyeball. Due to the swelling, the palpebral fissure was narrowed. Disturbed sensation in the area of the left orbital. Fracture in the craniofacial skeleton was not detected (Fig. 6). Body temperature was normal. The patient does not report comorbidities and allergies. The patient does not take medications and does not mention any social problems. Magnetic resonance imaging orbitals was performed, which showed an image of an abscess of the left orbit, exophthalmos and a forced course of the optic nerve (Fig. 7). Additionally, a craniofacial CT scan, lung X-ray, ECG were performed, a smear was taken for bacteriological examination and blood was taken for laboratory tests. The patient was administered ceftriaxone 1.2 g intravenous (IV) twice daily, Metronidazole 500 mg three times daily IV, ketoprofen 0.1 g twice daily, enoxaparin 0.4 ml once daily subcutaneous, dexamethasone 8 mg IV once daily. Additionally, drops containing dexamethasone and tobramycin every two hours were used for the left eye. Under general endotracheal anaesthesia, an incision and drainage of the left orbital phlegmon were performed from the supraorbital traumatic wound and suborbital incisions, resulting in abundant purulent exudate. The abscess cavity was rinsed with saline. A flow drain was introduced (Fig. 8). The wounds were surgically prepared and the necrotic masses were removed. In the postoperative period, the level of CRP and WBC was monitored—a decrease in CRP and WBC was observed. A control CT performed on the 3rd day after the procedure showed the correct position of the drain in the eye socket and a significant reduction in exophthalmos. The microbiological examination revealed the alarm pathogen Streptococcus pyogenes susceptible to empirical therapy, Klebsiella pneumoniae, Proteus mirabilis. On the 3rd day after the procedure, the patient reports a subjective sense of light in the left eye (Fig. 9). On the 8th day of hospitalization, the patient was returned to the Ophthalmology Department. The consequence of the injury and infection was permanent blindness of the left eye.

The most frequently encountered signs and symptoms include periorbital edema, restricted ocular movement, orbital pain, proptosis, periorbital erythrema, chemosis and vision deterioration—Table 1. [3, 8]–[39]

Bacterial etiology is the most common and regards pathogenes such as Streptococcus spp. [7, 11, 14, 16, 28, 31, 33, 35, 39, 40], Staphylococcus aureus [9, 36, 40] (also methycylin resistant Staphylococcus aureus [20, 21, 34, 40]) and Pseudomonas aeruginosa [24, 30, 41]. Additionally, wide spectrum of bacteria are rarely encountered: Haemophilus spp. [28, 39], Coagulase-negative staphylococcus [23, 40], Peptostreptococcus spp. [8, 27], Citrobacter freundii [11, 40], Enterobacter spp. [40], Enterococcus spp. [39, 40], Acinetobacter spp. [40], Actinomyces israelii [40], Diphteroids [40], Morganella Morgani [17], Proteus mirabilis [17, 40], Escherichia coli [40], Granulicatella Adiacens [22], Prevotella melaninogenica [27], Eikenella corrodens [28],, Propionibacterium acne [42], Pseudomonas stutzeri [38] as well as polymicrobial infections [3, 11, 28, 39, 40]. Gram-negative infections are at higher risk of visual deterioration or loss, especially in regard to Acinetobacter spp. [40] Fungal etiology occurs very infrequently and includes Exophiala dermatitidis [15] and Candida albicans [11]. Occasionally, the infection etiology remains unknown despite culture sampling and isolation attempt [10, 19, 29, 43]—according to Teena et al. 68.8% of orbit specimens finds the infectious pathogen [40]. Some articles omit stating exact etiology [12, 13, 26].

Orbital abscess formation originates from odontogenic, periorbital, sinonasal, traumatic, or systemic pathologies, like wise iatrogenic complications. Odontogenic pathogenesis includes incorrect or complicated intraoral interventions, such as tooth extractions and endodontic treatment [12, 19, 33, 35] as well as delayed dental procedures related to 'extreme phobia' of dental procedures and severe caries [8, 18]. Common ophthalmological procedures may result in orbital abscess: posterior subtendon injection [9, 15, 29, 34], strabismus surgery [16], trabeculectomy [38], canaliculitis surgical treatment [28], or orbital implants placement [3, 42]. Frequently, the abscess arises from dacryocystitis [17, 23, 27, 37, 44, 45], and rarely from concjuctivitis [20]. Another cause come from sinus pathologies such Pott's Puffy Tumor [13] or frontoethmoidal mucopyocele [30] as well as sinusitis and nonspecific upper respiratory infection [20, 46]. The important origin regards posttraumatic fractures, lacerations and impacted foreign bodies [11, 22, 26]. Finally, systemic conditions such as human immunodeficiency virus (HIV) infection [46], immunosuppression after transplantation [24] or congenital immunodeficiency (in pediatric population) [41]. There are cases where exact pathogenesis remains unknown [25, 32].

Orbital abscess sequels apply not only to the orbit, restricted ocular motility, impaired or lost vision, and central retinal artery occlusion. Infection may spread causing superior orbital fissure syndrome, cavernous sinus thrombosis, meningitis, brain abscess, and subdural empyema [23, 47]–[49]. On the other hand, Hughes et al. reported a case of an orbital abscess concomitant to aseptic meningitis and cavitory lung lesions which pathogenesis concerned severe caries. They claimed hematogenous spread of the infection, because maxillary sinus showed no infection. [8]

Ocular ultrasonography provides immediate assessment of an orbit and opportunity to follow treatment outcomes without unnecessary exposure to radiation [20, 21]. However, more accurate examinations such as CT or MRI are crucial to evaluate local extension and involvement of adjacent structures, especially before surgical treatment. Despite CT is the first line imaging technique in eye infections and pathologies, it has limited power to visualise orbital abscess. In case of severe symptoms and not significant CT examination, additional MRI scans should be performed [21, 25, 50]. According to Sepahdari et al. diffusion-weigted imaging (DWI) of MRI provides accurate imaging of orbital abscess and grants the sufficient tool for patients with renal insufficiency, if used without intravenous contrast. However, they performed a preliminary study with only 9 cases of orbital infections, including 2 lacrimal gland abscess, 2 eyelid abscess, extraconal abscess, intraconal abscess, and subperiosteal abscess [51]. Panoramic radiograph may be used to visualise oral pathologies in case of odontogenic origin of orbital abscess. [31]

Numerous conditions present similar symptoms as orbital abscess, possibly misleading the diagnosis, for instance: neoplasms—osteoma of the ethmoid sinus, [52], small cell neuroendocrine carcinoma of the orbit [53] plasmacytoma [54], infections—primary orbital tuberculosis [55], globe subluxation [56], or liquefied hydrogel implant accumulation [57]. On the other hand, physicians reported cases of true orbital abscess primarily misdiagnosed with other pathologies, such as retrobulbar haemorrhage [11], tumor [25], fronto-orbital mucocele, [32] or granulomatosis with polyangitis exacerbation [58]. Therefore, precise diagnostic process is crucial, including past medical history, clinical assessment, imaging, microbiological tests and histopathological evaluation.

According to current review, surgical treatment was necessary in 94% of cases. Abscess drainage is achieved via multiple approaches depending on its localisation: transculuncular, lateral or anterior orbitotomy, Caldwell-Luc approach, intranasal endoscopy, needle aspiration guided by ulstrasound, lower eyelid incision, subcilliar incisio, incision in four quadrants of the orbit. If it is necessary, surgical debridement of necrotic tissues is performed, as well as enucleation or exenteration. Antibiotic therapy is both, initial and supplementary to surgical treatment. Only two cases resolved with alone antibiotics administration—Table 2 [3, 8]–[28, 30, 32]–[39, 42].

Complete recovery succeed in 49% of cases, whereas 11% of patients recovered with vision loss, 9% with vision deterioration, 6% with persistent movement restrictions, 3% with exenteration, 3% with enucleation, 3% with residual enophatomos, 3% with residual proptosis, and 3% with corneal scarring. Exact results were not presented in 14% of cases. Fortunately, any patient died in the investigated reports [3, 8]–[28, 30, 32]–[39, 42].( Table 3)