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Indian Journal of Ophthalmology Vol. 62 No. 3

Fungal endophthalmitis following early and aggressive Wilkins; 1987. p. 195‑8.

treatment results in good visual outcome. 8. Weishaar PD, Flynn HW, Murray TG, Davis JL, Barr CC,
Gross JG, et al. Endogenous Aspergillus endophthalmitis.
References Clinical features and treatment outcomes. Ophthalmology
1998;105:57‑64.
1. Stevens DA, Moss RB, Kurup VP, Knutsen AP, Greenberger P,
Judson MA, et al. Allergic bronchopulmonary aspergillosis in cystic 9. Walsh TJ, Dixon DM. Nosocomial aspergillosis: Environmental
fibrosis‑state of the art: Cystic Fibrosis Foundation Consensus microbiology, hospital epidemiology, diagnosis and treatment.
Conference. Clin Infect Dis 2003;37:S225‑64. Eur J Epidemiol 1989;5:131‑42.

2. Agarwal M, Biswas J, Mathur U, Sijwali MS, Singh AK. Aspergillus 10. Gao H, Pennesi M, Shah K, Qiao X, Hariprasad SM, Mieler WF,
iris granuloma in a young male: A case report with review of et al. Safety of intravitreal voriconazole: Electroretinographic
literature. Indian J Ophthalmol 2007;55:73‑4. and histopathologic studies. Trans Am Ophthalmol Soc 2003;
101:183‑90.
3. Myles WM, Brownstein S, Dechenes J. Clinically unsuspected
11. Denning DW, Lee JY, Hostetler JS, Pappas P, Kauffman CA,
bilateral Aspergillus endophthalmitis. Can J Ophthalmol
Dewsnup DH, et al. NIAID mycoses study group multicenter trial
1996;32:182‑4.
of oral itraconazole therapy for invasive aspergillosis. Am J Med
4. Valluri S, Moorthy RS, Liggett PE, Rao NA. Endogenous 1994;97:135‑44.
Aspergilllus endophthalmitis in an immunocompetent individual.
12. Breit SM, Hariprasad SM, Mieler WF, Shah GK, Mills MD,
Int Ophthalmol 1993;17:131‑5.
Grand MG. Management of Endogenous Endophthalmitis with
5. Leibovitch I, Lai T, Raymond G, Zadeh R, Nathan F, Selva D. Voriconazole and Caspofungin. Am J Ophthalmol 2005;139:135‑40.
Endogenous endophthalmitis. A 13‑year review at a tertiary
hospital in South Australia. Scand J Infect Dis 2005;37:184‑9.
Cite this article as: Khan B, Vohra R, Kaur R, Singh S, A, V. Excellent outcome
6. Anaissie  EJ, Stratton  SL, Dignani  MC. Pathogenic Aspergillus
of Aspergillous endophthalmitis in a case of allergic bronchopulmonary
species recovered from a hospital water system: A 3‑year
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prospective study. Clin Infect Dis 2002;34:780‑9.
Source of Support: Nil. Conflict of Interest: None declared.
7. Charles S. Witreous Microsurgery. 2nd ed. Baltimore: Williams and

Neonatal orbital abscess Neonatal orbital abscess is extremely rare, it may be caused by

dacryocystitis,[1‑3] tooth bud abscess,[4] and ethmoidal sinusitis.
Poor outcome such as blindness, intracranial complications,
Khalil M Al‑Salem, Fawaz A Alsarayra, or even death has been reported. [1,5] Surgical drainage is
Areej R Somkawar generally recommended in cases of subperiosteal or intraorbital
abscess. [1] However, some reports have documented CT
evidence of subperiosteal orbital abscesses that was not found
Orbital complications due to ethmoiditis are rare in neonates.
at the time of surgery, and it was suggested that the condition
A case of orbital abscess due to acute ethmoiditis in a 28‑day‑old
might be treated successfully by antibiotics alone.[6]
girl is presented. A Successful outcome was achieved following
antimicrobial therapy alone; spontaneous drainage of the abscess
occurred from the lower lid without the need for surgery. From
Case Report
this case report, we intend to emphasize on eyelid retraction as A 28‑days‑old female, a product of normal vaginal delivery,
a sign of neonatal orbital abscess, and to review all the available weight (3.5 KG), presented with 2 days history of severe right
literature of similar cases. eye proptosis, fever (100.6 F) following an upper respiratory
tract infection. The baby was on breast feeding since birth.
Key words: Eyelid retraction, orbital infection, orbital neonatal
No maternal history of sexual transmitted disease, and the
abscess, neonatal abscess
pregnancy was uneventful.
Ocular examination showed severe right eye proptosis,
Access this article online minimal swelling of both upper and lower eyelids [Fig. 1].
Quick Response Code: Website: There was extra‑ocular motility restriction in all gazes.
www.ijo.in She had normal pupil and fundus exams. CT scan showed
a poorly‑defined, retrobulbar, slightly hypodense mass
DOI:
10.4103/0301-4738.116447
extending to the preseptal space, displacing the right medial
rectus and reaching up to the superior rectus. The ethmoidal
PMID: air spaces were inflamed. [Fig. 2] White blood cell count
*** was (19,200/mm3). Blood culture was negative for bacteria.
A diagnosis of right orbital cellulites with a medial orbital
Department of Ophthalmology, Mutah University, Al‑Karak, Jordan abscess was made, and the patient was started on intravenous
Correspondence to: Dr. Khalil M. Al‑Salem, Department of cefotaxime, ampicillin, and metronidazole in anticipation
Ophthalmology, Mutah University, 830910, Amman, 11183, Jordan. for surgical intervention. However, spontaneous drainage
E‑mail: [email protected] occurred prior to surgery. Proptosis of the right eye resolved
Manuscript received: 18.06.11; Revision accepted: 27.10.12 in the following 5 days along with the fever.
March 2014 Brief communications 355

Cultures were positive for Staphylococcus aureus sensitive has been reported after 2005, and it needs to be kept in mind
to methicillin. On the 6th day, motility and the upper eyelid while giving the proper antibiotics on presentation.[3,7,14]
retraction improved tremendously  [Fig.  3]. After 14  days of
Empirical choice of antibiotics should cover
intravenous antibiotics, the abscess completely resolved, along
methicillin‑resistant Staphylococcus aureus; being the most
with the eyelid retraction [Fig. 4].
common organism isolated from neonatal orbital abscess
Comments after 2005 as shown in  [Table  1]; so it will be a good choice
to use vancomycin, nafcillin, ampicillin, and first generation
Neonatal orbital abscess is extremely rare, it may be caused by cephalosporin. From [Table 1], it is appreciated that many
dacryocystitis,[1‑3] tooth bud abscess,[4] and ethmoidal sinusitis. case reports mentioned adding an antibiotic or replacing one
Eighteen cases are summarized in [Table 1]. because of the culture sensitivity test results; vancomycin being
T h e n u m b e r o n e c a u s e o f o r b i t a l a b s c e s s wa s the most common antibiotic added.
ethmoiditis  (confirmed in 7  cases by CT), congenital Neonatal orbital cellulitis has high probability for
Dacryocystitis (3 cases), and tooth bud infection (1 case). abscess formation since 15 cases ended up with abscess
Staphylococcus aureus was virtually isolated from all cases, (cases 1, 2, 4‑7, and 9‑17). Case 3 could not be fully characterized;
except for case 5; diplococcus pneumonia was isolated, the case 8 and 18 were labeled as cellulitis. Surgical treatment is the
case is atypical as the biopsy showed a choristoma‑like lesion preferred line of management in the presence of a collection
lined by a well‑differentiated, multi‑layered, non‑keratinizing on CT scan; 13 cases out of 15 were treated surgically when
epithelium with goblet cells and filled with inflamed stroma abscess formation was suspected or confirmed by CT scan. Our
with ectopic lacrimal gland tissue. [5] Aspergilous [12] and case is unique for the spontaneous drainage, which occurred
streptococcus[8] has been reported as concomitant infections with one day before the scheduled operation date.
Staphylococcus aureus. Nevertheless, orbital neonatal abscess
secondary to methicillin‑resistant Staphylococcus aureus (MRSA)

Figure 2: CT scan showed a poorly defined, retrobulbar, slightly

hypodense mass extending to the preseptal space, displacing the
right medial rectus and reaching up to the superior rectus. Ethmoidal
Figure 1:  28‑day‑old girl with right eye proptosis and retriction of EOM air cells are inflamed

Figure 3:  1 week after treatment. A small sinus is apparent in the Figure 4:  3 weeks after treatment. Complete resolution of the abscess
lower eyelid, draining of the pus in the orbit along with the eyelid retraction
Table 1: The table contains the literature review and summary of 18 neonatal orbital abscesses cases
356

Author Year Cases Age Sex Orbital Cellulitis Microorganism Causes Sepsis Drainage Outcome Eyelid Extraocular Initial antibiotics* Final
(days) CT form identified retraction motility antibiotics*
Burnard9 1959 1 14 F No Abscess Staphy. Aureus Not No Surgical Cure Not established Full EOM Chloramphenicol Penicillin and
established drainage streptomycin
    2 14 M No Abscess Staphy. Aureus Not Yes No Death Swollen eyelids Not determined Penicillin and Same
established streptomycin
    3 1 F No Not None Not No No Cure Mild eyelid Not determined Chloramphenicol Same
established established swelling
Maruszczak5 et al. 1979 4 27 M No Abscess Staphy. Aureus “Conjunctival No Surgical Cure Eyelid lag Fully restricted Methicillin, Same
malformation” (open) streptomycin.
    5 10 F No Abscess Diplo. “Conjunctival No Surgical Cure Not determined Not determined Not mentioned Not
Pneumoniae Cyst (open) mentioned
Saunders and 1993 6 15 F Yes Abscess Staphy. Aureus Ethmoiditis No Surgical Cure Not established Not determined Flucloxacillin and Gentamicin
Jones10 (open) ceftazidime added
Wiess et al.1 1993 7 5 F Yes Abscess Staphy. Aureus. Congenital No Surgical Cure Swelling of the Not determined Cefuroxime Same
Dacryocy‑stitis (open) eyelid
Charramendieta 1997 8 10 F Yes Cellulitis Staphy. Aureus Ethmoiditis No No Cure Swelling of Not determined Ceftazidime and Same
and Monasterolo11 eyelid amikacin
Reddy et al.12 1999 9 10 M Yes Abscess Staphy. Aureus+ Ethmoiditis No Surgical Cure Swelling of Not determined Cloxacillin, Cloxacillin,
Aspergillus (open) upper eyelid amikacin, Gentamicin
amphotercin B
Cruz et al.6 2001 10 21 F Yes Abscess None Ethmoiditis No Surgical Cure Not established Fully restricted Cephalothin Same
(open)
    11 16 F Yes Abscess Staphy. Aureus Ethmoiditis Yes Spontaneous Cure   Not determined Oxacillin, amikacin Same
Klusmann 2001 12 10 F Yes Abscess Staphy. Aureus, Not No Surgical Cure Permanent Not determined Ampicillin, Same
et al.8 Streptococcus B established (open) lagophthalmia oxacillin,
gentamycin
Fluss et al.13 2002 13 17 F Yes Abscess Staphy. Aureus Not No Surgical Cure Swelling of the Full extraocular Vancomycin and Floxacillin
Indian Journal of Ophthalmology

established (open) eyelid motility gentamicin

Green and Maun4 2002 14 24 M Yes Abscess Staphy. Aureus Ethmoid Yes Surgical Cure Swelling of Restricted Ampicillin and Vancomycin,
sinuses and (open) eyelid EOM gentamicin gentamicin,
tooth buds cefuroxime
Anari et al.7 2005 15 28 M Yes Abscess MRSA Ethmoiditis No Surgical Cure Eyelid swelling Right sided Flucloxacillin, Vancomycin,
(open) diviation cefotaxime rifampicin
Rogers et al.14 2007 16 13 M Yes Abscess MRSA Ethmoiditis No Endoscopic Cure Mild eyelid Not determined Clindamycin Clindamycin
surgery swelling
Mohan et al.2 2007 17 22 F Yes Abscess Staphy. Aureus Congenital No Open Cure Swelling of the Not determined Ceftazidime, Ceftazidime,
dacryocystitis surgery eyelid amikacin amikacin

Rutar3 2009 18 12 M Yes Cellulitis MRSA Congenital Yes No Cure Not determined Not determined Vancomycin Same
dacryocystitis
Present case 2011 19 28 F Yes Abscess Staphy. Aureus Ethmoiditis No Spontaneous Cure Eyelid Full restriction Cefotaxime, Same
retraction, of EOM ampicillin and
eyelid swelling metronidazole
Vol. 62 No. 3
March 2014 Brief communications 357

Finally, from [Table 1], it is clear that there is little information 7. Anari S, Karagama YG, Fulton B, Wilson JA. Neonatal disseminated
on extraocular motility and eyelid retraction as only 4 cases had methicillin‑resistant Staphylococcus aureus presenting as orbital
restriction of extra‑ocular motility,[4‑7] and only two had eyelid cellulitis. J Laryngol Otol 2005;119:64‑7.
retraction.[5,8] It is worth noting that Klusmann[8] reported 8. Klusmann A, Engelbrecht V, Unsöld R, Hassler W, Gärtner J.
permanent lagophthalmia in a 10‑day‑old neonate, which Retrobulbar abscess in a neonate. Neuropediatrics 2001;32:219‑20.
had some residue after 2 months of treatment. In our case, the 9. Burnard ED. Proptosis as the first sign of orbital sepsis in the
girl had eyelid retraction, which resolved spontaneously after newborn. Br J Ophthalmol 1959;43:9‑12.
successful treatment. 10. Saunders MW, Jones NS. Periorbital abscess due to ethmoiditis in
a neonate. J Laryngol Otol 1993;107:1043‑4.
References 11. Charramendieta EZ, Monasterolo RC. Ethmoidal sinusitis during
the neonatal period. An Esp Pediatr 1997;46:79‑80.
1. Weiss GH, Leib ML. Congenital dacryocystitis and retrobulbar
abscess. J Pediatr Ophthalmol Strabismus 1993;30:271‑2. 12. Reddy SC, Sharma HS, Mazidah AS, Darnal HK, Mahayidin M.
Orbital abscess due to acute ethmoiditis in a neonate. Int J Pediatr
2. Mohan E, Chandravanshi S, Udhay P. Retrobulbar orbital abscess Otorhinolaryngol 1999;49:81‑6.
secondary to dacryocystitis in a neonate. Ophthal Plast Reconstr
Surg 2007;23:238‑40. 13. Fluss J, Pósfay‑Barbe K, Rossillion B, Rilliet B, Suter S. An unusual
intraorbital abscess in a neonate. J Pediatr Ophthalmol Strabismus
3. Rutar T. Vertically acquired community methicillin‑resistant 2002;39:295‑7.
Staphylococcus aureus dacryocystitis in a neonate. J AAPOS
2009;13:79‑81. 14. Rogers GA, Naseri I, Sobol SE. Methicillin‑resistant
Staphylococcus aureus orbital abscess in a neonate. Int J Pediatr
4. Green LK, Mawn LA. Orbital cellulitis secondary to tooth bud abscess Otorhinolaryngol Extra 2007;2:99‑101.
in a neonate. J Pediatr Ophthalmol Strabismus 2002;39:358‑61.
5. Maruszczak D, Krarup JC, Fledelius HC. Orbital abscess in
two neonates, deriving from conjunctival malformations. Acta Cite this article as: Al-Salem KM, Alsarayra FA, Somkawar AR. Neonatal
Ophthalmol (Copenh) 1979;57:643‑8. orbital abscess. Indian J Ophthalmol 2014;62:354-7.
6. Cruz AA, Mussi‑Pinhata MM, Akaishi PM, Cattebeke L, da Silva T,
Source of Support: Nil. Conflict of Interest: None declared.
Elia J Jr. Neonatal orbital abscess. Ophthalmology 2001;108:2316‑20.

Bilateral intraocular dirofilariasis A 38‑year‑old Indian woman presented to our Outpatient

Department in north India with complaints of redness in
her right eye since 6 months. She had no history of recent
Viney Gupta, Preeti Sankaran, Mohanraj, travel. On examination, the right eye had mild conjunctival
Jyotish Chandra Samantaray1, Vimla Menon congestion. Her vision was 6/6 in both eyes without glasses.
Slit lamp examination revealed a live motile transparent
worm in the anterior chamber of her right eye [Fig. 1]. The
Ocular dirofilariasis mostly presents as a subconjunctival or eyelid worm was not adherent to the cornea or iris. Cross‑sectional
lesion.[1] Intraocular dirofilarial infestation is rare.[2,3] We report a thickness measured by ultrasound biomicroscopy was 130
case of a young woman who was accidentally detected to have microns. There was no inflammatory reaction in the anterior
a live motile worm in the anterior segment in one eye and a chamber. On dilated fundus examination of the left eye, a
cystic lesion on the optic disc in the other eye. To our knowledge, small lesion, approximately 1/10th of the size of optic disc
bilateral intraocular dirofilariasis has never been reported. was noted on the superonasal quadrant optic disc. The lesion
was confirmed to be separate from the disc and contained
Key words: Dirofilaria, intraocular dirofilaria, worm inflammatory debris on posterior segment optical coherence
tomography [Fig. 2]. No scolex was noted. Computed
tomography of brain and orbits revealed no abnormality.
Access this article online
Stool examination was normal. There was no hepatomegaly
Quick Response Code: Website: or splenomegaly. Her hemogram, including eosinophil counts
www.ijo.in was normal.
DOI: Under topical anesthesia, two paracentesis were made in
10.4103/0301-4738.116252
the anterior chamber of the eye. The worm extruded with
PMID: the aqueous. Morphologically, the features of the worm
*** were consistent with an adult Dirofilaria repens. The worm
was unsheathed with a blunt head and a tapering tail. It was
20‑mm in length, surrounded by a thick cuticle, with multiple
Department of Ophthalmology Dr. Rajendra Prasad Center for transverse ridges. Under the cuticle, a thick muscular layer
Ophthalmic Sciences, 1Department of Microbiology, All India Institute was seen. Postoperatively, the right eye remained quiet with
of Medical Sciences, New Delhi, India
no inflammatory episode. The cystic lesion in the left eye did
Correspondence to: Dr. Prof. Viney Gupta, Dr. Rajendra Prasad Centre not show further change over 3 months. In view of normal
for Ophthalmic Sciences, All India Institute of Medical Sciences, visual acuity and no ocular inflammation in the left eye, no
New Delhi, India. E‑mail: [email protected] intervention was performed. The patient remains under close
Manuscript received: 28.12.11; Revision accepted: 01.02.13 follow‑up.