E-ISSN 0976-2892 Case Report A Case of Odontogenic Orbital Cellulitis Causing Blindness: A Case Report Delhi J Ophthalmol 2013; 24 (2): 102-105 DOI: http://dx.doi.org/10.7869/djo.2013.22 Vimlesh Sharma, Laltanpuia Aim: To report a case of odontogenic orbital cellulitis causing blindness in young male Chhangte, Vijay Joshi, Swati Methods: We report a rare case of odontogenic orbital cellulitis secondary to periodontal abscess, Gupta, Kalpana due to which a young male lost his sight. Department of ophthalmology Results: After extensive clinical examination and investigations diagnosis of odontogenic orbital Government Medical College, cellulitis. Patient took incomplete treatment and showed negligence while taking treatment for Haldwani,Uttarakhand, India recurrent periodontal abscess. As a result he developed orbital cellulitis and temporal fossa abscess, which ultimately caused blindness in his right eye. *Address for correspondence Discussion: Orbital Cellulitis is the infection of the soft tissues behind the orbital septum. Orbital cellulitis is a life threatening infection. It is an ocular emergency that not only threatens vision but also can lead to life-threatening complications such as cavernous sinus thrombosis, meningitis, and brain abscess. The major causes of orbital cellulitis are sinusitis (58%), lid or face infection (28%), foreign body (11%), and hematogenous (4%), odontogenic 2-5%. Odontogenic i.e tooth related causes of orbital cellulitis are very less. Laltanpuia Chhangte (MS) Keywords : orbital cellulitis • periodontal abscess • odontogenic • blindness Department of ophthalmology Government Medical College, Orbital cellulitis is a life threatening treat patients as though they have orbital Haldwani, Uttarakhand, India infection of the soft tissues behind the cellulitis. Both conditions are more Email id: [email protected] orbital septum.1 It is an ocular emergency common in children than in adults, that not only threatens vision but also and preseptal cellulitis is much more can lead to life-threatening complications common than orbital cellulitis.4 such as cavernous sinus thrombosis, The major causes of orbital meningitis, and brain abscess.2,3 It must cellulitis are sinusitis (58%), lid or face be distinguished from preseptal cellulitis infection (28%), foreign body (11%), and (sometimes called periorbital cellulitis), hematogenous (4%), odontogenic 2-5%. which is an infection of the anterior Staphylococcus and Streptococcus are portion of the eyelid. Neither infection the most common causative organisms involves the globe itself. Although in adults, Haemophilus influenzae in preseptal and orbital cellutis may be children. Less common organisms are confused with one another because Pseudomonas and Esterichia coli.5,6 both can cause ocular pain and eyelid The warning signs of orbital swelling and erythema, they have very cellulitis are a dilated pupil, marked different clinical implications. Preseptal ophthalmoplegia, loss of vision, cellulitis is generally a mild condition afferent papillary defect, papilledema, that rarely leads to serious complications, perivasculitis, and violaceous lids.5 whereas orbital cellulitis may cause loss of vision and even loss of life. Orbital Case Report cellulitis can usually be distinguished A 30 years old male presented to from preseptal celulitis by its clinical the eye OPD chief complaint of loss features (ophthalmoplegia, pain with of vision of right eye with swelling, eye movements and proptosis) and by redness of right eye associated with imaging studies; in cases in which the swelling of right sided temporal region distinction is not clear, clinicians should for 10 days. He had a history of dental www.djo.org.in 102 ISSN 0972-0200 Case Report Sharma V et al abscess with fistula in the right upper jaw 14 days back, cellulitis involving preseptal and intraorbital compartments pus can be extruded out of the fistula when pressing the of the right orbit, more on the lateral aspect. (Figure 2). upper jaw and right temporal regions, following which he These findings were consistent with right orbital cellulitis. started complaining of loss of vision and swelling of right The patient’s past medical history was not significant but eye. He denied any history of nasal obstruction or discharge his habit of drinking was. He used to drink in excess 40-60 or ear problem. He gave a history of on off dental pain for units of alcohol every day for the past 8 years and smoked last 1 year. He took incomplete treatment due to negligence 10-20 cigarettes per day, chew paan occasionally. He had no every episode. His general physical examination was within history of drug abuse. normal limits except for right side temporal swelling and tenderness. His right eye was swollen, erythematous, and tender to palpation and very mild proptosis (Figure 1a). His right pupil was mid dilated and non-reacting. The right conjunctiva was erythematous and chemosed associated with lid edema and moderate restriction of eyeball movement (Figure 1b). His dental examination shows a fistula present in the upper jaw opposite right premolar tooth with expression of pus through the fistula on pressing the upper jaw region (Figure 1b) suggesting periodontal abscess. At the time of presentation, his Snellen’s visual acquity was no perception of light in the right eye and 6/6 in the left eye. On fundoscopy, nasal blurring of optic disc margin and hyperaemic disc was seen, rest was within normal limits. 2(a) Figure 2 (a): MRI of cranium and orbit showing cellulitis involving right temporal 1(a) fossa, preseptal and intraorbital compartments of the right orbit Figure 1 (a): Of the face showing mild swelling of right cheek and periorbital area involving eyelid, and mild proptosis of the right eye 1(b) 2(b) Figure 1 (b): Showing a fistula opposite the root of premolar tooth After hospital admission, a MRI SCAN of the cranium and orbits revealed cellulitis involving abscess involving Figure 2 (b): MRI of cranium and orbit showing decreased Intensity of the optic right temporalis muscle and upper masseter muscle, also nerve is with mild proptosis in RE 103 Del J Ophthalmol 2013;24(2) E-ISSN 0976-2892 A Case of Odontogenic Orbital Cellulitis Causing Blindness: A Case Report Case Report Ceftriaxone, amikacin and metronidazole were started and sinus flora (Staphylococcus and Streptococcus species). empirically. About eight hours later, the patient underwent Orbital cellulitis or subperiosteal abscess from ENT evaluation and incision and drainage of the temporal odontogenic causes are relatively rare complications and abscess. Gram’s stain of material from surgery revealed these can occur along several pathways due to specific moderate neutrophils and moderate gram positive cocci in anatomic structure of facial bone. The first pathway is the clusters. But on Zieh Nielsen staining, no acid fast bacilli most common one via the sinus because the roots of molar was found. Cultures yielded predominant growth of and premolar tooth are adjacent to the base of maxillary Staphyloccus aureus(> 100000 colonies/ml grown). Drug sinus; the infection of a tooth invades the maxillary sinus Sensitivity test shows sensitivity against the drugs we directly. Then the inflammation or infection of the sinus were currently administering the patient and also against spreads into the orbit through bone erosion between the ampicillin, cefixime, cefotaxime, cephalexin, ciprofloxacin, orbit and the maxillary sinus or through ethmoid sinus or erythromycin, levofloxacin, ofloxacin, tetracycline, infraorbital canals.7,8 The second pathway is the one through trimethoprim/sulfamethoxazole and gentamicin, and the facial soft tissue over buccal cortical plate, spreading to resistance against ceftazidime. periorbital tissues. The third pathway is the one that infection The patient was discharged after completing the 7-day of a molar or premolar tooth invades the infratemporal and course of injectable antibiotics and extraction of the right pterygopalatine fossa, spreading into the orbit through the premolar tooth for prevention of further attack (Figure 3). inferior orbital fissure.8-10 Infection of a tooth can also spread All Signs and symptoms subsided at the time of discharge into the orbit along the facial vein and the ophthalmic vein except that the vision could not be restored due to negligence by hematogeneous regurgitation because the veins of the of seeking medical advice at the most crucial time. face, eyes, nasal cavity and sinus are all connected without valves.8 With regard to our patient, it is thought that the findings of invasion of cheek area and temporal fossa demonstrate the correspondence with the second and third pathways. There are normal floras such as Staphylococcus epidermidies, S. aureus, Streptococcus salivarius, S. mutans, Lactobacillus sp., Eubacterium sp., and Bacteroides gingivalis in the mouth which can cause infection.12-13 As S. aureus had been identified from the microbiologic culture of the patient, it was highly suspected that this complication was induced by odontogenic infection. There are some case reports which described a visual loss from an odontogenic complication14, but the cases had not shown typical findings of tension orbit and eyeball deformation caused by severe proptosis and optic nerve traction. The direct dissemination of infection to the optic nerve may be considered the possible cause of visual loss that occurred in our patient.15 Administration of high dose steroid in the patient with Figure 3: