Orbital Abscess—Two Case Reports with Review

Periorbital infections lead to severe condition of the orbital abscess, and eventually to sight loss, and even death. Current study aims in reviewing the literature regarding orbital abscess in adult patients and presenting 2 original cases. A surgical intervention to drain the abscess and a revision of the orbital was required. A review of literature is also reported focusing on aetiology and treatment options dealing with an orbital abscess.


Introduction
Periorbital infections lead to severe condition of orbital abscess, and eventually to sight loss, and even death [1,2]. They carry the risk of rapid deterioration, hence require immediate management [3].
In 1970, Chandler et al. proposed the classification of orbital complications depending on its extention: I-preseptal cellulitis; II-orbital cellulitis; III-subperiosteal abscess; IV-orbital abscess; V-cavernous sinus thrombosis [4]. Current study aims in reviewing literature regarding orbital abscess in adult patients and presenting 2 original cases.

Case Report 1
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).

Case Report 2
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.

Discussion
Owing to the retrospective nature of this study, it was granted an exemption by the Poznan University of Medical Science review board.
The first literature case reports of orbital abscess originated in 1884 [5,6] Orbital abscess formation occur in 8% of patients with retroseptal orbital cellulitis [7].

Sequels
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] Imaging 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]

Treatment
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    [39,42].
Funding None.

Declarations
Conflict of interest The author declare that they have no conflict of interest.
Ethical Approval Ethical approval was not necessary for the preparation of this article.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.