Indian Journal of Ophthalmology

ORIGINAL ARTICLE
Year
: 2000  |  Volume : 48  |  Issue : 2  |  Page : 129--34

Orbital abscess: Management and outcome


N Suneetha, RR Battu, RK Thomas, A Bosco 
 Department of Ophthalmology, St. John's Medical College Hospital, Bangalore, India

Correspondence Address:
N Suneetha
Department of Ophthalmology, St. John«SQ»s Medical College Hospital, Bangalore
India

Abstract

Purpose: To discuss the diagnosis, management and outcome of various types of orbital abscess. Methods: The medical records of 13 patients diagnosed and treated for orbital abscess were reviewed. The sources of infection included: paranasal sinusitis (n = 5), odontogenic origin of infection (n = 4), one each, temporal fossa abscess, palatal abscess, furuncle on the nose, and secondary to retrobulbar injection of steroid. Computed tomographic scans revealed the presence of an abscess in all 13 cases. Associated findings on CT scan included: sinus disease (n = 8), cavernous sinus thrombosis (n = 2) and subdural empyema (n = 2). All patients were treated with intensive, multiple, intravenous antibiotics and early surgical drainage. Results: Purulent material collected surgically from the orbit cultured Staphylococcus aureus (n = 3), two each Pseudomonas aeruginosa, Proteus mirabilis, Acinetobacter species and one each β-haemolytic Streptococci, Citrobacter frundi and Enterobacter. Final visual acuity was good in 6 patients (6/12 - 6/6) and no light perception in 6 others. Visual acuity could not be recorded in the infant. The other complications were intracranial abscess (n = 4), cavernous sinus thrombosis (n = 2) and restricted ocular motility (n = 1). Conclusions: A high index of suspicion is necessary, along with early institution of appropriate diagnostic imaging, and aggressive medical and surgical treatment for a favourable outcome in cases of orbital abscess.



How to cite this article:
Suneetha N, Battu R R, Thomas R K, Bosco A. Orbital abscess: Management and outcome.Indian J Ophthalmol 2000;48:129-34


How to cite this URL:
Suneetha N, Battu R R, Thomas R K, Bosco A. Orbital abscess: Management and outcome. Indian J Ophthalmol [serial online] 2000 [cited 2020 Mar 29 ];48:129-34
Available from: http://www.ijo.in/text.asp?2000/48/2/129/14890


Full Text

With institution of treatment with appropriate antibiotics the incidence of orbital abscess has decreased significantly.[1] However the potential for serious and at times life-threatening complications necessitates a high index of suspicion, prompt diagnosis, intensive antibiotic therapy and appropriate surgical drainage. In this retrospective study, we reviewed records of 13 patients with orbital abscess, to evaluate the diagnostic procedures implemented, their efficacy in detecting the abscess, the primary sources of infection, the common causative organisms, the treatment protocols and the final outcome in terms of visual acuity, motility disturbances, neurological deficits and other systemic complications.

 Materials and Methods



The records of 13 patients with orbital abscess were reviewed. All patients were treated at the Department of Ophthalmology, St. Johns Medical College and Hospital, Bangalore, India, from 1992 to 1998. Patient data included age, gender, duration of symptoms, primary source of infection, visual acuity, pupillary response, proptosis, extraocular muscle movements, neurological status, computerised tomographic (CT) scan findings, culture reports, antibiotics administered, surgical procedures done, final visual outcome, and complications.

On admission, patients were immediately put on multiple, intensive, intravenous antibiotics. The Table summarizes the different combination of antibiotics used and the culture-sensitivity adjusted antibiotic changes. The antibiotics were changed, following culture reports in 6 patients. All patients with dental origin of infection received metronidazole.

All patients underwent emergency surgical drainage of the orbital abscess. The location of the abscess and the presence of associated diseases and complications determined the surgical approach (Table). Surgery followed a multidiscipinary approach involving ophthalmologists, otorhinolaryngologists and neurosurgeons, so that all purulent material was drained at the same surgical procedure. The orbital skin incisions included 3 lateral, 4 medial, 2 superior and 1 inferior location. In the patients with subperiosteal abscess, a skin incision made along the orbital margin was deepened up to the periosteum. The periosteum was then incised and elevated away from the bone, to reach the subperiosteal space. Two of these patients had their cheek abscesses drained into the oral cavity. Two patients with sinus involvement underwent orbital abscess drainage through a medial skin incision along the orbital margin, with external ethmoidectomy and maxillary antrostomy. Two patients with orbital abscess secondary to paranasal sinusitis underwent functional endoscopic sinus surgery with orbital decompression. An exenteration was done for the patient with aspergillosis as she developed early signs of meningeal irritation despite treatment with Amphotercin B and transnasal surgical decompression. Craniotomy was done in one patient with subdural empyema. The peribulbar and retrobulbar abscess was approached transconjunctivally. Large areas of necrotising scleritis with prolapse of intraocular contents was found; evisceration had to be done in this patient.

 Results



A total of 13 cases (11 males and 2 females) of orbital abscess were treated from 1992 to 1998. During the same time period 81 cases of orbital and periorbital inflammation were seen in the department, which included preseptal cellulitis (n = 24), orbital cellulitis (n = 19), orbital mucormycosis (n = 10), and orbital pseudotumours (n = 15). The average age of the patients with orbital abscess was 31 years (6 months-60 years) At the time of presentation, the duration of orbital symptoms ranged from 2 to 7 days in 11 patients. In the other two patients (# 9 and # 11), the duration of symptoms was 15 days and 2 months respectively. Sudden onset of orbital pain, headache, swelling of eyelids, reduced vision and fever were the common symptoms. The patient with actinomycotic infection had symptoms and signs similar to those abscesses caused by bacteriae. However, the patient with Aspergillus infection presented with loss of vision, ophthalmoplegia and headache, but no inflammatory signs and symptoms. All patients had varying degrees of lid oedema, conjunctival congestion, chemosis, proptosis, restricted ocular motility, reduced visual acuity and abnormal pupillary response [Figure:1]. The ocular fundus was normal in patients with a clear media (n = 10). In two patients it was not visualised due to corneal haze secondary to exposure keratitis. The visual acuity at presentation varied from no light perception (n = 6) to 6/6 (n = 1). Some of the patients were too ill or too young to respond to Snellen's visual acuity testing. Only two patients presented with altered sensorium.

Maxillary and/or ethmoidal sinusitis was the primary source of infection in 5 (38.4%) patients. Only one of these patients had a previous history suggestive of chronic sinusitis. Four (30.7%) patients underwent dental extraction or had a history of dental abscess 4-15 days prior to the onset of orbital symptoms. One patient each had spontaneous onset of temporal fossa abscess and palatal abscess. Furuncle on the face (n = 1), and retrobulbar injection (n = 1) of steriods for retinal vasculitis were the other predisposing conditions.

Plain and contrast, axial and coronal, computerized scans of the orbit, paranasal sinuses and brain were done in all cases. Only two patients did not cooperate for coronal cuts. Subperiosteal abscesses characterized by localized homogenous or heterogeneous radioopaque masses with smooth margins that were contrast enhancing and with convexity towards the orbit were found in 6 patients [Figure:2]. Orbital abscesses characterized by homogeneous or heterogeneous masses, gas in the orbit and loss of orbital fat shadows were found in 6 patients [Figure:3]. Severe proptosis can cause stretching of the optic nerve and tenting of the globe [Figure:2]. A peribulbar and retrobulbar abscess was found in one patient [Figure:4]. Sinus involvement in 8 patients (this included two patients with dental origin of infection and one with palatal infection), subdural empyema in 2 patients [Figure:5], and cavernous sinus thrombosis in 2 patients were also visualised on CT scan.

Purulent material collected surgically from the orbit cultured Staphylococcus aureus (n = 3), two each Pseudomonas aeruginosa, Proteus mirabilis, Acinetobacter species and one each β-haemolytic Streptococci, Citrobacter frundii and Enterobacter. Swabs from the nose, temporal fossa and the palate were also sent for culture and sensitivity in 7 patients. In 5 of these patients the organisms and their sensitivity patterns corresponded to that cultured from the orbit (Table). Blood cultures were negative in 6 patients. Patient # 12 had reformation of the abscess, which was drained again and the culture grew a different organism (Table).

Six patients had no complications with good visual recovery (6/12-6/6), no residual proptosis, no extraocular motility disorders or neurological deficits. This includes the two patients who had cavernous sinus thrombosis and subdural empyema. Intracranial abscess developed 7-10 days after the orbital abscess was drained in two patients in this group; both of them recovered completely with intensive medical therapy only. In the patients with no light perception, there was no improvement in visual acuity. One of these patients had residual proptosis and restricted abduction. One patient in this group had to undergo exenteration and another, evisceration. There was no mortality in this series.

 Case Reports



Two illustrative cases are briefly described here

Case 1 (Patient # 9)

A 35-year-old male was admitted with pain, swelling, redness, of the right eye of 2-3 days' duration. Associated blocked nose and running nose was also present. On initial examination, patient was afebrile, and well oriented. Right-sided orbital swelling with mild proptosis and chemosis was present. Extraocular muscle movements were restricted in all directions of gaze. Right pupil was sluggish, and visual acuity was 6/18. The right fundus was normal. CT scan of the orbit showed a right-sided medial subperiosteal abscess with right etmoidal and maxillary sinusitis with clinical suspicion of orbital abscess. The patient was immediately started on intravenous, crystalline pencillin, gentamicin and metronidazole.

The abscess was drained through a medial orbitotomy and the sinuses cleared by functional endoscopic sinus surgery. Orbital pus cultured Staphlococcus aureus. The orbital symptoms subsided rapidly after surgery. Visual acuity at one-month follow up was 6/6.

Case 2 (Patient # 8)

A 14-year-old male was admitted to the Department of general surgery with a history of pain, swelling and purulent discharge from the right temporal fossa area of 1 week duration. Patient developed swelling of the right forehead and right eye following admission, for which an ophthalmology consultation was sought.

On examination, the patient was febrile and toxic. A swelling over the right temporal fossa, with 3 small stab incisions and purulent discharge was seen. Associated swelling of the right forehead and dependent oedema of the right lids were also present. There was an early restriction of the right dextroelevation and dextroversion. A brisk pupillary light reaction was present in both eyes. Anterior segment and fundus was normal. Visual acuity was better than counting fingers at 6 meters both eyes. The left eye was normal.

The patient was on treatment with systemic cephalexin and metronidazole. Hourly monitoring of pupillary response, ocular motility and systemic parameters like pulse, blood pressure and respiratory rate was ordered. Four hours later a deterioration in ocular motility with an early afferent pupillary defect was detected. An immediate CT scan of the orbit was done which showed a lateral subperiosteal abscess. An emergency orbitotomy was done under general anaesthesia. At the same time the temporal fossa abscess was drained. Orbital pus cultured Staphylococcus aureus sensitive to cephazolin. The antibiotic was accordingly changed.

The extraocular motility improved and pupils became brisk with a reduction in the temperature and toxic signs 48 hours following surgery. However, there was a recurrence of fever 5 days later. A repeat CT scan of the brain and orbit was done on the seventh postoperative day which showed a small subdural empyema. This was not present on the first CT scan. Fortunately this improved without further neurosurgical intervention. Only the antibiotics dose was increased. Visual acuity at the time of discharge from the hospital was 6/6 in the right eye with no other complication.

 Discussion



Orbital abscess is a serious infective condition of the orbit. It is a disease of adults unlike orbital cellulitis which is most commonly seen in children.[2] Orbital abscess forms during stages 3 and 4, in the evolution of orbital infections. When orbital cellulitis is adequately treated, it resolves without complications, almost always the outcome in children. In adults orbital cellulitis is uncommon, though complications are frequently seen.

Orbital abscess is characterised by lid oedema, conjunctival chemosis, proptosis, afferent pupillary defect, visual impairment and restricted ocular motility. These signs vary depending upon the size and location of the abscess, duration of the disease and virulence of the organisms. The signs and symptoms are similar in both the cellulitic and the abscess stages, with increased severity in the latter stage. Eccentric globe displacement is one specific sign of a subperiosteal abscess. The only definitive method of differentiating a cellulitic stage from an abscess is diagnostic imaging which includes CT scan and β-scan ultrasonography of the orbit. In our series, an abscess was strongly suspected in four cases based on the clinical findings. However, this was not confirmed on CT scan and the condition resolved with medical treatment. All cases of orbital cellulitis not responding after 24-48 hours of intensive antibiotic therapy should undergo CT scan and B-scan ultrasonography. Presence of neurological signs and symptoms portend intracranial spread of infection. This was present in two patients in this series (# 3 and 7). However, (patient # 9) with a large subdural empyema was well oriented with no meningeal and neurological signs.

Primary infection of the orbit occurs through direct innoculation following fractures, orbital foreign bodies and ocular surgeries. Orbital abscess commonly occurs secondary to spread of infection from contiguous structures like the paranasal sinuses, teeth, face, scalp, lids, lacrimal gland, sac and intracranium. Direct spread occurs either through the multiple foramina, suture lines and congenital dehiscence in the bones or along the tissue planes. The indirect mode of spread is by infective thrombophlebitis of the many valveless veins which communicate between the orbit and the surrounding structures. In most studies, paranasal sinuses have been implicated as the most common source of infection, varying from 43%3 to 71%.[4] In our series paranasal sinusitis was found in 5 patients (38.4%). Even when the infections are primarily of odontogenic origin, in most cases the spread to the orbit occurs through the paranasal sinuses because both maxillary premolars and molars are in close apposition with the floor of the maxillary sinus. Two of our patients with odontogenic infection had maxillary and ethmoidal sinusitis. The other two patients had a buccal abscess which tracked into the lateral subperiosteal space. Though not seen in this series, odontogenic infections have a propensity to cause severe complications.[5-7] This may be due to inappropriate treatment where anaerobic bacteria are causative agents and/or, multiple organisms are involved.[8]

Culture and sensitivity patterns in our patients were similar to those in other reports.[1-3] The unusual pathogens in this group were Actinomycosis Israeli and Aspergilius species. Both paients presented with acute onset of proptosis, defective ocular motility and in one case rapid loss of vision. In the patient (# 9) with actinomycosis and a subdural empyema infection resolved completely, with surgical drainage and prolonged penicillin therapy. The patient with aspergillosis (patient # 11) had acute onset of visual loss, pain and ocular motility disorder and then went into chronic phase. Despite endoscopic sinus surgery, transethmoidal orbital decompression, and intravenous amphotericin B the patient needed exenteration.

Anaerobic bacteria are important pathogens in odontogenic infections,[6] but were not detected in this series. In our opinion blood culture yields are poor, especially if the patients have already received antibiotics. Culture and sensitivity patterns of specimens from the nose, temporal fossa and palate were similar to those cultured from the orbits in 5 out of 7 patients. Hence this investigation could, be a very useful guide in instituting early and appropriate antibiotic therapy. Other reports,[8,9] do not however, confirm to our conclusion.

Sinus radiographs, CT scans and B-scan ultrasonography help in the diagnosis of an orbital abscess. Radiography mainly reveals paranasal sinus diseases characterised by sinus opacification, mucosal thickening and presence of fluid level. Gas or fluid-gas level in the orbit is strongly suggestive of orbital abscess, though absence of this finding does not necessarily rule out an orbital abscess. On a CT scan the orbit is a high contrast area, with the muscle cone, optic nerve and the globe well contrasted against the less dense orbital fat. An orbital abscess is seen as a homogeneous or heterogeneous mass with contrast enhancing margins. Orbital cellulitis is characterised by obliteration of orbital fat shadows. Sinusitis, inflammation, abscess formation in the surrounding structures and intracranial complications are usually well delineated. Because of these advantages, CT scan is the most comprehensive imaging technique in patients with suspected orbital infection.[8,10] In our series an orbital abscess was detected in all 13 cases on CT scan, so also sinusitis in 8 patients and intracranial complications in 3 patients. B-scan ultrasonography is equally effective in outlining anteriorly located orbital abscess.[8,10] It has no role in the diagnosis of apically located abscesses. However, it is cost effective and useful in the follow up, where serial ultrasonographs can be taken to monitor the efficacy of the treatment.

In the early nineties the patients in this series were treated with crystalline penicillin, gentamicin, cloxacillin, and metronidazole. Pencillin was withdrawn as many organisms were found resistant to this antibiotic. More recently combination of vancomycin-ceftazidime and cefataxime-amikacin have also been found very effective, as almost all organisms cultured in this group were sensitive to one of the drugs used. Penicillin, however, remains the drug of choice in actinomycosis and metronidazole was given to all patients with dental infections. We recommend that all patients should receive multiple, high dose, intravenous antibiotics.

In addition to intensive antibiotic therapy, frequent monitoring of systemic and ocular parameters is essential. Systemic monitoring includes recording heart rate, blood pressure and temperature, and neurological evaluation for level of sensorium and deficits. Ocular parameters include the degree of proptosis, state of eyelid skin, position of the globe, visual acuity, and pupillary response. Any change in vision and pupillary response warrants a change in treatment strategy. This is well illustrated in case report 2 (Patient # 8).

Postoperative monitoring is warranted to detect reformation of abscess and complications. A subperiosteal abscess tracks posteriorly towards the apex and causes early compression of the optic nerve. Orbital abscesses by virtue of increased intraorbital pressure cause proptosis and stretching of the optic nerve. Orbital abscesses also cause infective and toxic optic neuropathy. Delayed surgical intervention invariably leads to visual loss and other cranial nerve palsies as demonstrated in this study. We suggest that once the diagnosis of orbital abscess is etablished it should be drained immediately and adequately.[1,5,6,11] All surgical procedures should be done under general anaesthesia involving the otorhinolaryngologists, ophthalmologists and neurosurgeons as the situation demands unless the poor general condition is a contraindication. Drainage must be done everyday; prone/face down position of the patient facilitates good drainage.

In this series, the complications occurred mainly in patients who presented late. Loss of vision occurred in 7 patients who had no light perception or dilated and fixed pupils at time of presentation. The duration of orbital symptoms was 5-15 days in all cases except in the patient with peribulbar and retrobulbar abscess; he had rapid progression of symptoms with loss of vision over 24 hours. Intracranial complications at the time of presentation were also found in patients who presented late.

Orbital abscess although an uncommon ophthalmic disease, has the potential for serious complications. This demands immediate and aggressive action from the treating ophthalmologist. High index of suspicion and awareness of this condition helps. All cases with suspected orbital infection should be admitted for intensive antibiotic therapy and monitoring. Any clinical sign or symptom suggestive of orbital abscess warrants immediate CT scan. Early surgical intervention is necessary when the presence of an abscess is confirmed.

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