Case 1
A 67-year-old female presented to our hospital with progressive swelling and pain of the right eye for 2 weeks. Initially, the swelling was small as an acne vulgaris lesion at the middle edge of the nose. The patient went to a clinic and an oral unknown drug was administered. But, during the last week before admission, she felt that the swelling was getting worse so that she couldn’t open her right eye. She had a history of dental and maxillary pain 5 years ago, but she only used over-the-counter drugs to relieve the pain. The history of sinusitis was unknown. She reported no history of trauma, ocular disease, ocular surgery, hypertension, or diabetes.
Ophthalmological examination of the right eye showed diffuse upper eyelid swelling and redness extended to the lower eyelid area with active pus production and skin crusts (shown in Fig. 1.A). The right eyeball could not be assessed due to the tight closure of the eyelid. On the left eye, examination showed normal condition with visual acuity 6/9 with immature cataract, and other parts were within normal limit. Based on clinical condition, the patient was diagnosed having severe orbital cellulitis with skin complication of the right eye.
Pus specimens from the skin lesion and blood culture were collected for microbiological tests include direct examination, cultures and antimicrobial sensitive-resistance tests. The Gram stain revealed Gram negative rods. The blood test results showed increase of inflammation with leukocytosis (21.8 x103/µL), high CRP (300 mg/L), and also found hyperglycemia (392 mg/dL) with high HbA1c level (11.1%). Orbital CT-Scan with contrast demonstrated pre- and post-septal cellulitis of the right orbit that attached to the eye globe and extended to the right ethmoid, frontal and maxillary sinuses, and also extended to the soft tissue around the nasal region (shown in Fig. 1.B). Right maxillary sinusitis was a prominent finding in both CT-Scan and paranasal sinuses X-Ray. The bilateral nasolacrimal ducts also showed moderate signs of infection or inflammation.
Based on laboratories and imaging investigations, the patient was diagnosed with orbital cellulitis of the right eye with periorbital abscess and rhinosinusitis due to suspected bacterial infection. The patient was hospitalized and was started with ampicillin-sulbactam (4x1.5g) intravenously and chloramphenicol eye ointment three times daily. To manage other comorbidities we consulted other specialties for advice, including ENT, dermato-venereology, endocrinology, dentistry, and plastic reconstructive surgery. The patient was also diagnosed with type 2 diabetes mellitus, immature cataract of the left eye, periodontitis, and dental gangrene.
Initial empirical systemic antibiotic therapies were given including ampicillin-sulbactam 4x1.5 g IV, and chloramphenicol topical eye ointment. Systemic analgetic was also given to relieve the pain. Other supported treatment include lesion wound care, nasal wash, and fluticasone furoate spray twice daily. Microbiological test from the base of skin ulceration was also performed. From endocrinology, the patient was diagnosed with type 2 diabetes mellitus based on increased HbA1C result, and started to give insulin therapy for glycemic control.
Two days after the initial treatment, there was no clinical improvement seen from the lesions. After discussion with the dermato-venereology department, we decided to change systemic antibiotic to of piperacillin-tazobactam 4x4.5 g intravenously and clindamycin 3x600 mg oral. The blood glucose was also not controlled with the insulin therapy and we reconsulted to the endocrinology department.
On the 4th day of hospitalization, the eyelid swelling and redness were decreasing and the eyeball movement improved and showed mild restriction in all cardinal gaze direction. The visual acuity of the right eye was 0.16. From eye examination with slit lamp, seen marked conjunctival and ciliary injection, but no sign of corneal defect or ulceration, lens opacities was found on the right eye (shown in Fig. 1.C.D.E) Funduscopic examination showed enlargement of cup-to-disk ratio (0.6–0.7). The intraocular pressure was within normal limits, so this could be possible of suspected normal-tension glaucoma or a normal variance. Further examination should be examined for reassure of glaucoma management.
Functional Endoscopic Sinus Surgery (FESS) and debridement were performed by ENT and joined with plastic surgeon departments. Three days post-surgery, a significant improvement was seen with new regimen of antibiotics (shown in Fig. 2.A). The laboratory test showed decreasing in the leukocyte count (8.3 x103/µL), the blood glucose was also well-controlled (< 200 mg/dL). The pus culture result showed Klebsiella pneumonia and Enterobacter cloacae which were sensitive to piperacillin-tazobactam yet resistant to ampicillin-sulbactam. Five days after the surgery, it was seen improvement on clinical presentation (shown in Fig. 2.B).
The patient was discharged on the 4th day after FESS surgery. The infection and inflammation of the right eye were properly managed by the combination of multidisciplinary team, a suitable regimen of antibiotics, adequate control of blood glucose level, surgical treatment, and appropriate wound care management. On the last eye examination, the inflammation on the right eye were reduced quite significantly and the best corrected visual acuity had improved from decimal 0.16 to 0.4. Intraocular pressure and eyeball movement were within normal limits.
Oral antibiotics were still given to control the infection. We recommended the combination of levofloxacin 1x500 mg for 7 days and clindamycin 3x600 mg for 3 days. Chloramphenicol eye ointment, insulin injection, and other supportive drugs were also given to achieve optimal healing. On follow up, clinical improvement was seen on the 10th day after surgery (shown in Fig. 2.C).
Case 2
A 59-year-old female came to our emergency room presenting with swollen painful eyelid of her right eye three days before admission without complaining of blurry vision or watery eye. There was no history of trauma. She compressed her right eye with warm water, came to the nearest clinic, and was given levofloxacin 1x500mg, omeprazole 2x20mg, and paracetamol 3x500mg orally. On the next day, the pain and swollen of the right eye worsened, and there was pus coming out from the wound near the corner of the eye. She denied any history of sinusitis or toothache before. However, she had a history of the same complaints 12 years ago when she was working in Saudi Arabia. The ophthalmologist recommended surgery as a treatment, but she refused. She was regularly consuming 2 mg dexchlorpheniramine maleate and 0.5 mg dexamethasone 4–5 times a week in one year without prescription.
The ophthalmology examination of the right eye revealed a restriction of the ocular movement to the superior, superonasal, nasal, inferonasal, temporal, and superotemporal regions. The position of the right eye was hypertrophic. Visual acuity of the right eye was 6/30 and intraocular pressure was normal. There was a hyperemic, edematous mass at the inferior palpebra extended to maxillary, sized 8.5 x 9 cm. The palpation of the mass revealed warm, tenderness with soft consistency around the palpebra and hard consistency at the maxillary region. There was no undulation detected. There was a fistula seen at 8 mm from the medial canthus, but no discharge was coming out from the fistula. Slit-lamp examination on the right eye revealed conjunctival injection and chemosis at the inferior and temporal quadrants, mild discharge, erosion at inferomedial cornea sized 2x1.5 mm with positive fluorescein staining. Pupil was round with no relative afferent pupil defect, and posterior segment evaluation was within normal limit. Examinations of the left eye were within the normal limit. (shown in Fig. 3.A.B.C).
The laboratory results confirmed high leukocytes (14.780/uL), high blood glucose level (573mg/dL), and high CRP level (51.4 mg/L). The orbital CT-scan identified diffuse edema of the soft tissue in the superior and inferior palpebra to right maxilla with right ethmoid and maxillary sinusitis and bilateral mastoiditis (shown in Fig. 3.D). The diagnoses were orbital cellulitis, conjunctivitis and corneal erosions of the right eye.
This patient was also consulted to Otorhinolaryngology/ENT department. She was diagnosed with acute unilateral rhinosinusitis and treated conservatively with nasal spray and irrigation. The internal medicine department was also assessed and treated this patient as type 2 diabetes mellitus. Cavities filling and dental scaling was also performed by dentistry department.
We treated the patient with levofloxacin eye drop 6 times daily, artificial tears hourly, chloramphenicol eye ointment 3 times of the right eye, ampicillin-sulbactam 4x1.5 g, and metronidazole 3x500 mg intravenously, mefenamic acid 3x500 mg orally. On the next day, the redness of the right eye was still prominent, with a minimal yellowish discharge coming out from the fistula. Pus was taken for microbiological direct examination and culture. Gram-positive cocci were revealed on direct examination. Furthermore, corneal erosion enlarged to size 3.5x1.8 mm, thus levofloxacin eye drop was given hourly and other previous medications were continued.
On the third day, the pain and redness of the right eye were gradually reduced and the patient felt easier to open her eye. Visual acuity of the right eye was improved to 6/15 and the ocular movement was also improving. The hyperemic mass on her right eye and cheek was significantly reduced and the wound gradually closed and improved over time (shown in Fig. 4.A). Corneal erosion was also improving until fluorescein staining was negative. However, the pus culture showed no growth of microorganisms. We tapered levofloxacin eye drop to 6 times daily and other medications were continued. The incision and drainage of the right eye were postponed until the 5th day of antibiotic administration to evaluate clinical response with medications.
On the 5th day of observation, the general condition was improved significantly. The consistency of the hyperemic, edematous diffuse mass on the inferior palpebra became softer, yet spontaneous yellowish discharge was still positive (shown in Fig. 4.B). The blood glucose levels were also reduced significantly (mostly < 200 mg/dL). Careful and tight monitoring were continued until the 7th day and clinical result responded well to the treatment (shown in Fig. 4.C). She was discharged after 7 days in the hospital, and we gave levofloxacin eye drop 6 times daily, artificial tears hourly, chloramphenicol eye ointment, ampicillin-sulbactam 3x375 mg, metronidazole 3x500 mg, and ranitidine 2x150 mg orally. We also reminded the patient to visit our clinic one week later.
On one week follow up, our patient visited our clinic without any complaint. The ocular movement was adequate to all quadrants, best-corrected visual acuity was 6/6 on both eyes, and intraocular pressure was within normal limit. Hyperemic and edematous on the inferior palpebra to the maxillary region was minimal without any pus nor blood. The anterior and posterior segment of the eye was within the normal limit. She was given artificial tears 3 hourly, and chloramphenicol eye ointment 2 times a day on the right eye and asked to revisit in one month. Two months after hospitalization, the patient was satisfied with her appearance as proven by complete resolution of the orbital cellulitis (shown in Fig. 4.D).