 |
|
Orbital Cellulitis and Abscess Secondary to Dacryocystitis
Arch Ophthalmol. 2002;120:1096-1099.
The symptoms of nasolacrimal duct obstruction include epiphora, conjunctivitis,
and mucoid discharge. Dacryocystitis may develop when bacterial overgrowth
occurs in the stagnant fluid of the lacrimal sac. Whereas acute dacryocystitis
is usually characterized by tender preseptal cellulitis, chronic dacryocystitis
typically manifests as painless purulent reflux from the lacrimal sac. Antibiotic
therapy is indicated for acute infections, and dacryocystorhinostomy is the
definitive treatment.
Although anterior extension into the preseptal soft tissues occurs more
often in acute dacryocystitis, orbital extension can occur, although rarely,
and result in orbital cellulitis and abscess formation.1-9
Posterior extension into the orbit can result in devastating visual compromise.
We describe a series of 4 patients with orbital cellulitis and abscesses secondary
to dacryocystitis (Table 1).
|
|
|
|
Table 1. Orbital Cellulitis and Abscesses Secondary to Dacryocystitis
in 4 Patients
|
|
|
Report of Cases
Case 1
A 38-year-old woman had a history of epiphora for many years but declined
surgical treatment. She had 1 previous episode of dacryocystitis that resolved
with systemic antibiotics. She sought care because of a 1-week history of
painful swelling and decreased vision in her left eye.
On examination, her visual acuity was 20/20 OD and no light perception
OS. A left afferent pupillary defect was present. Her left globe was markedly
proptotic, tense to retropulsion, and restricted in all fields of gaze. Dilated
funduscopic examination revealed hyperemia of the left disc. A computed tomographic
scan revealed a medial orbital abscess. No sinus disease was noted.
The patient was started on intravenous cefazolin and gentamicin sulfate.
She underwent an emergent orbitotomy with abscess drainage through a medial
Lynch incision. Copious amounts of necrotic purulent material were drained.
A direct communication was noted between the posterior aspect of the lacrimal
sac and the intraconal space. The intraconal abscess was also evacuated. A
dacryocystorhinostomy was performed. Cultures grew Staphylococcus
aureus. Postoperatively, the patient had resolution of the orbital
inflammation and proptosis, but her visual acuity remained no light perception
OS.
Case 2
A 64-year-old woman was hospitalized with jaundice, anorexia, and hepatic
failure secondary to chronic alcoholism. Two days after admission, swelling
of the right upper and lower eyelids was noted. She was afebrile but had a
white blood cell count of 22.5 x 103/µL
with leukocytosis. Empiric intravenous vancomycin hydrochloride was started
by the admitting service. Ophthalmic consultation was obtained.
Her visual acuity was light perception OD. An afferent pupillary defect
was present. Marked right proptosis, diminished extraocular motility, chemosis,
and conjunctival hyperemia were also noted. Dilated fundus examination showed
right choroidal folds and retinal edema. A computed tomographic scan showed
a large, irregular mass in the medial and posterior orbit displacing the globe
and optic nerve. There was enlargement of the medial rectus muscle and contrast
enhancement of the posterior sclera. The bony orbit was intact, and the sinuses
were clear.
A differential diagnosis of orbital cellulitis with abscess, idiopathic
orbital inflammation, hematogenous dissemination, and malignancy was considered.
Intravenous antibiotics were continued with minimal improvement. During the
next several days, the patient's medical condition deteriorated due to gastrointestinal
bleeding and ascites. Once the patient was medically stable, a medial orbitotomy
through a Lynch incision was performed. Upon dissection between the medial
and superior recti muscles into the intraconal space, an abscess was encountered
surrounding the optic nerve. The abscess was noted to be extending from the
area of the lacrimal sac. Purulent material was drained, and a communication
with the abscess was identified. Several dacryoliths were removed. An osteotomy
into the nasal cavity and a dacryocystorhinostomy with silicone stents were
performed. Cultures grew nonenterococcal group D streptococci, Streptococcus viridans, and Streptococcus intermedius. Postoperatively, the patient had resolution of proptosis and improved
ocular motility, except for an adduction deficit. Her visual acuity remained
light perception OD.
Case 3
A 62-year-old woman sought care from her ophthalmologist with a 5-day
history of tearing and swelling of the left upper and lower eyelids. Her ocular
history included nasolacrimal obstructive symptoms for many years and prior
episodes of dacryocystitis. Oral cephalexin monohydrate (250 mg, 4 times daily)
was prescribed. During the next 2 days, she developed proptosis and chemosis
of the left eye and was referred for consultation.
Her visual acuity with correction was 20/20 OD and 20/60 OS. A trace
left afferent pupillary defect was noted. Marked chemosis and erythema were
noted, and 13 mm of relative proptosis was measured. A motility examination
showed severely restricted ductions of the left globe. Her intraocular pressure
was 19 mm Hg OD and 46 mm Hg OS. Dilated fundus examination showed slight
hyperemia of the left nerve. The patient was afebrile but had a white blood
cell count of 11.6 x 103/µL
with leukocytosis. An orbital computed tomographic scan showed a large medial
orbital mass contiguous with the lacrimal sac, suggestive of an abscess. The
paranasal sinuses were clear. The patient was hospitalized, and intravenous
cefazolin and gentamicin were initiated. Urgent medial orbitotomy through
a Lynch incision was performed. The lacrimal sac and the superior aspect of
the nasolacrimal duct were found to be grossly dilated and tense. The sac
was opened, and copious purulent material was removed and cultured. Three
large dark-gray dacryoliths were extracted from the sac. Examination of the
sac revealed a fistulous communication extending from the sac into the medial
intraconal space. A dacryocystorhinostomy was performed with silicone stents.
During the next several days, the patient showed gradual improvement.
Cultures grew S viridans, S intermedius, and Veillonella parvula. Infectious disease
consultation recommended 3 weeks of intravenous cefazolin and 1 week of oral
cephalexin. Follow-up at 8 weeks after the operation revealed complete resolution
of the proptosis, edema, and chemosis. Adduction was nearly full. Visual acuity
measured 20/25 OS. A residual left afferent pupillary defect was present with
slight pallor of the left optic nerve.
Case 4
A 51-year-old, otherwise healthy man sought care because of a 2-day
history of right-sided medial canthal swelling, pain, redness, and tearing.
He was previously seen by his internist, who prescribed oral erythromycin
stearate. For several weeks before seeking care, he noted intermittent epiphora
and swelling that could be relieved with digital massage. His medical history
was unremarkable except for a penicillin allergy.
On examination, his visual acuity was 20/20 OU. Medial canthal and lower-eyelid
edema and erythema were present. His motility was full, and there was no proptosis.
Initial computed tomographic scanning showed an enlarged lacrimal sac and
surrounding soft tissue inflammation (Figure
1, A). Intravenous vancomycin and gentamicin were initiated. During
the next 2 days, improvement was noted; however, on the third day, when the
patient complained of increased pain, his examination showed 3 mm of proptosis,
increased resistance to retropulsion, diminished extraocular movements, and
marked induration of the medial canthal region. His vision remained 20/20
OU, and no afferent pupillary defect was present. A repeated computed tomographic
scan showed marked orbital soft tissue inflammation and a medial orbital abscess
(Figure 1, B). Intravenous trovafloxacin
mesylate was initiated for improved anaerobic coverage. When no clinical improvement
was noted 24 hours later, the patient underwent an endoscopic dacryocystorhinostomy
with evacuation of copious purulent material from the lacrimal sac. Silicone
stents were also placed. The results of cultures were negative. A lacrimal
sac biopsy specimen showed acute and chronic inflammation. Follow-up at 1
week showed intact vision, resolution of edema, full ocular motility, and
no proptosis. His stents were removed at 6 months, and his dacryocystorhinostomy
was patent.
|
|
|
|
A, Coronal computed tomographic scan of a 51-year-old, otherwise
healthy man shows dacryocystitis before orbital cellulitis and abscess formation.
Note the proximity of the lacrimal sac to the intraconal space. B, Coronal
computed tomographic scan shows progression to orbital abscess (arrow), indenting
the globe.
|
|
|
Comment
Patients with nasolacrimal duct obstruction seek treatment primarily
to relieve symptoms of epiphora, irritation, and mucoid discharge. If obstruction
progresses to acute dacryocystitis, pain and swelling of the lacrimal sac
region occur, necessitating systemic antibiotics and definitive surgical treatment.
In chronic dacryocystitis, patients often obtain temporary relief of symptoms
with external decompression of the lacrimal sac. If dacryocystitis is untreated,
orbital extension has been reported.1-9
These cases are summarized in Table 2.
|
|
|
|
Table 2. Orbital Extension in Patients With Dacryocystitis*
|
|
|
This study describes our series of 4 patients who developed orbital
cellulitis and orbital abscesses arising from dacryocystitis. Of 4 patients,
3 had intraconal spread of the orbital abscess and culture-proven bacterial
infections; 3 patients also had prior episodes of dacryocystitis. Each of
these findings deserves further discussion.
Most patients with dacryocystitis develop preseptal cellulitis and not
orbital extension. This has been attributed to the orbital septum by its insertion
on the posterior lacrimal crest, limiting spread to the orbit.5
Several other barriers exist posteriorly, including the lacrimal fascia, the
posterior limb of the medial canthal ligament, and deep heads of the pretarsal
and preseptal orbicularis muscles (Horner muscle). Because the orbital septum
and the medial canthal ligament insert on both the anterior and posterior
lacrimal crests, we postulate that the main barrier to posterior extension
is the deep heads of the preseptal and pretarsal orbicularis muscles. Hence,
the anatomic barriers to prevent egress from the lacrimal sac are greater
posteriorly than anteriorly.
Once the posterior barriers of the lacrimal sac have been breached,
access to the intraconal space is essentially unimpeded, except for the Tenon
fascia and the intermuscular septum. Because of the anterior and inferior
location of the nasolacrimal sac in relation to the globe, a channel of communication
can form between the medial and inferior rectus muscles directly to the intraconal
space. Intraconal abscess formation can lead to rapid vision loss, necessitating
urgent surgical intervention.
Although intravenous antibiotics were initiated immediately in all patients,
surgical drainage is the definitive treatment. Surgical intervention in all
4 cases consisted of dacryocystorhinostomy with placement of silicone stents
and orbital abscess drainage. Of 4 cases, 3 had an external approach, and
1 case had an endoscopic intranasal approach. All patients had a patent dacryocystorhinostomy
at the last follow-up visit (range, 2-19 months).
The clinical bacteriological characteristics of dacryocystitis in adults
have been studied previously.10 In our series,
2 of 4 patients had polymicrobial infections, 1 patient had a single organism,
and 1 had no isolates. When examining the isolates from our series and the
previously reported cases from Table 2, we find that, in general, younger patients (<3 years) tended to have single
isolates, and older patients tended to have polymicrobial infections. These
findings parallel those seen in orbital abscesses secondary to sinus disease.11
In our series, 3 of 4 patients had a prior history of dacryocystitis.
In fact, of the reported cases in Table
2, 6 (40%) of 15 had prior dacryocystitis. In addition, 5 (33%)
of 15 had dacryoliths, including 2 patients who did not have a prior history
of dacryocystitis but had dacryoliths found intraoperatively. We believe that
prior dacryocystitis is a risk factor for orbital extension. Distension of
the lacrimal sac during episodes of dacryocystitis can stretch the lacrimal
sac walls and its posterior barriers (posterior limb of the medial canthal
ligament, Horner muscle, and septum). These barriers weaken from distension
and cause breaches and rarefaction, increasing the likelihood of posterior
spread.
Other causes of orbital cellulitis secondary to dacryocystitis have
been postulated.1-2 In 1
case report, the authors speculated that postoperative soft tissue swelling
from blepharoplasty might have contributed to the obstruction of an already
compromised lacrimal outflow system.2 Other
authors have theorized that orbital involvement could have resulted from spread
of infection from the lacrimal sac to the ethmoid sinus through the lamina
papyracea, with subsequent extension from the sinus to the orbit.1 None of our cases had any evidence of sinus disease,
and it is more likely that any sinus opacification seen is secondary to adjacent
inflammation from the dacryocystitis or unrelated sinus disease. Other possible
causes include hematogenous spread from other systemic sources and, in some
cases, a primary orbital cellulitis that can extend into the lacrimal sac
without the dacryocystitis necessarily being causal.
In summary, our series of orbital cellulitis and abscess secondary to
dacryocystitis has been presented. Orbital cellulitis and abscess can rapidly
progress to an intraconal abscess and can cause severe visual sequelae if
untreated. Prompt recognition and appropriate surgical management of this
condition are necessary to prevent vision loss. Prior dacryocystitis is a
risk factor for developing orbital extension, and patients with prior episodes
of dacryocystitis who elect not to have a lacrimal bypass operation should
bewarned of these potential consequences.
AUTHOR INFORMATION
This study was supported in part by an unrestricted grant from Research
to Prevent Blindness, Inc, New York, NY.
The views expressed in this article are those of the authors and do
not reflect the official policy of the US Army, the Department of Defense,
or the US government.
Don O. Kikkawa, MD
La Jolla, Calif
Grant W. Heinz, MD
Tucson, Ariz
Ronald T. Martin, MD;
William N. Nunery, MD
Indianapolis, Ind
Andrew S. Eiseman, MD
Washington, DC
Corresponding author and reprints: Don O. Kikkawa, MD, University
of California, San Diego, Department of Ophthalmology, 9415 Campus Point Dr,La
Jolla, CA 92093-0946 (e-mail: dkikkawa{at}ucsd.edu).
REFERENCES
|
1. Ahrens-Palumbo MJ, Ballen PH. Primary dacryocystitis causing orbital cellulitis. Ann Ophthalmol. 1982;14:600-601.
PUBMED
2. Allen MV, Cohen KL, Grimson BS. Orbital cellulitis secondary to dacryocystitis following blepharoplasty. Ann Ophthalmol. 1985;17:498-499.
PUBMED
3. Campolattaro BN, Lueder GT, Tycheson L. Spectrum of pediatric dacryocystitis: medical and surgical management
of 54 cases. J Pediatr Ophthalmol Strabismus. 1997;34:143-153.
PUBMED
4. Lawless M, Martin F. Orbital cellulitis and preseptal cellulitis in childhood. Aust N Z J Ophthalmol. 1986;14:211-219.
PUBMED
5. Mauriello JA, Wasserman BA. Acute dacryocystitis: an unusual cause of life-threatening orbital
intraconal abscess with frozen globe. Ophthal Plast Reconstr Surg. 1996;12:294-295.
PUBMED
6. Molgat YM, Hurwitz JJ. Orbital abscess due to acute dacryocystitis. Can J Ophthalmol. 1993;28:181-183.
PUBMED
7. Ntountas I, Morschbacher R, Pratt D, Patel BC, Anderson RL, McCann JD. An orbital abscess secondary to acute dacryocystitis. Ophthalmic Surg Lasers. 1997;28:758-761.
PUBMED
8. Warrak E, Khoury P. Orbital abscess secondary to acute dacryocystitis. Can J Ophthalmol. 1996;31:201-202.
PUBMED
9. Weiss GH, Leib LM. Congenital dacryocystitis and retrobulbar abscess. J Pediatr Ophthalmol Strabismus. 1993;30:271-272.
PUBMED
10. Coden DJ, Hornblass A, Haas BD. Clinical bacteriology of dacryocystitis in adults. Ophthal Plast Reconstr Surg. 1993;9:125-131.
PUBMED
11. Harris GJ. Subperiosteal abscess of the orbit: age as a factor in the bacteriology
and response to treatment. Ophthalmology. 1994;101:585-595.
ISI
| PUBMED
SECTION EDITOR: W. RICHARD GREEN, MD
|
