a case of odontogenic orbital cellulitis causin blindness in young male

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Case Report
A Case of Odontogenic Orbital
Cellulitis Causing Blindness: A
Case Report
Delhi J Ophthalmol 2013; 24 (2): 102-105
Orbital cellulitis is a life threatening
infection of the soft tissues behind the
orbital septum.1
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.2,3
It must
be distinguished from preseptal cellulitis
(sometimes called periorbital cellulitis),
which is an infection of the anterior
portion of the eyelid. Neither infection
involves the globe itself. Although
preseptal and orbital cellutis may be
confused with one another because
both can cause ocular pain and eyelid
swelling and erythema, they have very
different clinical implications. Preseptal
cellulitis is generally a mild condition
that rarely leads to serious complications,
whereas orbital cellulitis may cause loss
of vision and even loss of life. Orbital
cellulitis can usually be distinguished
from preseptal celulitis by its clinical
features (ophthalmoplegia, pain with
eye movements and proptosis) and by
imaging studies; in cases in which the
distinction is not clear, clinicians should
treat patients as though they have orbital
cellulitis. Both conditions are more
common in children than in adults,
and preseptal cellulitis is much more
common than orbital cellulitis.4
The major causes of orbital
cellulitis are sinusitis (58%), lid or face
infection (28%), foreign body (11%), and
hematogenous (4%), odontogenic 2-5%.
Staphylococcus and Streptococcus are
the most common causative organisms
in adults, Haemophilus influenzae in
children. Less common organisms are
Pseudomonas and Esterichia coli.5,6
The warning signs of orbital
cellulitis are a dilated pupil, marked
ophthalmoplegia, loss of vision,
afferent papillary defect, papilledema,
perivasculitis, and violaceous lids.5
Case Report
A 30 years old male presented to
the eye OPD chief complaint of loss
of vision of right eye with swelling,
redness of right eye associated with
swelling of right sided temporal region
for 10 days. He had a history of dental
Keywords : orbital cellulitis • periodontal abscess • odontogenic • blindness
Aim: To report a case of odontogenic orbital cellulitis causing blindness in young male
Methods: We report a rare case of odontogenic orbital cellulitis secondary to periodontal abscess,
due to which a young male lost his sight.
Results: After extensive clinical examination and investigations diagnosis of odontogenic orbital
cellulitis. Patient took incomplete treatment and showed negligence while taking treatment for
recurrent periodontal abscess. As a result he developed orbital cellulitis and temporal fossa abscess,
which ultimately caused blindness in his right eye.
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.
Vimlesh Sharma, Laltanpuia
Chhangte, Vijay Joshi, Swati
Gupta, Kalpana
Department of ophthalmology
Government Medical College,
Haldwani,Uttarakhand, India
Laltanpuia Chhangte (MS)
Department of ophthalmology
Government Medical College,
Haldwani, Uttarakhand, India
Email id: drtpchhangte18@gmail.com
*Address for correspondence
DOI: http://dx.doi.org/10.7869/djo.2013.22

2. 103 Del J Ophthalmol 2013;24(2)
ISSN 0972-0200
Case Report
abscess with fistula in the right upper jaw 14 days back,
pus can be extruded out of the fistula when pressing the
upper jaw and right temporal regions, following which he
started complaining of loss of vision and swelling of right
eye. He denied any history of nasal obstruction or discharge
or ear problem. He gave a history of on off dental pain for
last 1 year. He took incomplete treatment due to negligence
every episode. His general physical examination was within
normal limits except for right side temporal swelling and
tenderness.
His right eye was swollen, erythematous, and tender to
palpationandverymildproptosis(Figure1a).Hisrightpupil
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.
After hospital admission, a MRI SCAN of the cranium
and orbits revealed cellulitis involving abscess involving
right temporalis muscle and upper masseter muscle, also
cellulitis involving preseptal and intraorbital compartments
of the right orbit, more on the lateral aspect. (Figure 2).
These findings were consistent with right orbital cellulitis.
The patient’s past medical history was not significant but
his habit of drinking was. He used to drink in excess 40-60
units of alcohol every day for the past 8 years and smoked
10-20 cigarettes per day, chew paan occasionally. He had no
history of drug abuse.
Sharma V et al
Figure 1 (a): Ofthefaceshowingmildswellingofrightcheekandperiorbitalarea
involvingeyelid,andmildproptosisoftherighteye
Figure 2 (a): MRIofcraniumandorbitshowingcellulitisinvolvingrighttemporal
fossa,preseptalandintraorbitalcompartmentsoftherightorbit
Figure 2 (b): MRIofcraniumandorbitshowingdecreasedIntensityoftheoptic
nerveiswithmildproptosisinRE
Figure 1 (b): Showingafistulaoppositetherootofpremolartooth
1(a)
1(b)
2(a)
2(b)

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Case ReportA Case of Odontogenic Orbital Cellulitis Causing Blindness: A Case Report
Figure 3: Extractedpremolartoothcariescausingperiodontalabscess
Ceftriaxone, amikacin and metronidazole were started
empirically. About eight hours later, the patient underwent
ENT evaluation and incision and drainage of the temporal
abscess. Gram’s stain of material from surgery revealed
moderate neutrophils and moderate gram positive cocci in
clusters. But on Zieh Nielsen staining, no acid fast bacilli
was found. Cultures yielded predominant growth of
Staphyloccus aureus(> 100000 colonies/ml grown). Drug
Sensitivity test shows sensitivity against the drugs we
were currently administering the patient and also against
ampicillin, cefixime, cefotaxime, cephalexin, ciprofloxacin,
erythromycin, levofloxacin, ofloxacin, tetracycline,
trimethoprim/sulfamethoxazole and gentamicin, and
resistance against ceftazidime.
The patient was discharged after completing the 7-day
course of injectable antibiotics and extraction of the right
premolar tooth for prevention of further attack (Figure 3).
All Signs and symptoms subsided at the time of discharge
except that the vision could not be restored due to negligence
of seeking medical advice at the most crucial time.
Discussion
The most important element in the care of patients with
preseptal cellulitis and orbital cellulitis is differentiating
the two infections. Preseptal cellulitis is much more
common than orbital cellulitis, and patients with preseptal
cellulitis can be treated as outpatients with oral antibiotics.
If the globe can be examined and the patient has full gaze
without pain, CT imaging can be deferred. Red flags for the
more worrisome diagnosis of orbital cellulitis or abscess
include proptosis and decreased extraocular movements.
These signs warrant hospitalization, parenteral antibiotics
that include coverage for H. Influenzae, CT, and surgical
specialty consultation. The inability to completely examine
the globe for intact vision and extraocular movements also
necessitates CT scanning.
Treatment in both preseptal and orbital cellulitis should
include coverage of Haemophilus species as well as skin
and sinus flora (Staphylococcus and Streptococcus species).
Orbital cellulitis or subperiosteal abscess from
odontogenic causes are relatively rare complications and
these can occur along several pathways due to specific
anatomic structure of facial bone. The first pathway is the
most common one via the sinus because the roots of molar
and premolar tooth are adjacent to the base of maxillary
sinus; the infection of a tooth invades the maxillary sinus
directly. Then the inflammation or infection of the sinus
spreads into the orbit through bone erosion between the
orbit and the maxillary sinus or through ethmoid sinus or
infraorbital canals.7,8
The second pathway is the one through
the facial soft tissue over buccal cortical plate, spreading to
periorbitaltissues.Thethirdpathwayistheonethatinfection
of a molar or premolar tooth invades the infratemporal and
pterygopalatine fossa, spreading into the orbit through the
inferior orbital fissure.8-10
Infection of a tooth can also spread
into the orbit along the facial vein and the ophthalmic vein
by hematogeneous regurgitation because the veins of the
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
infection can be controversial. But some authors reported
that active administration of steroid at an early stage
may be helpful for faster symptomatic improvement.16,17
Although co-administration of high dose steroid along with
antibiotics did not aid in the recovery of vision in our patient,
it is considered somewhat helpful for blocking further
aggravation of inflammation. Complications of untreated
infections include periosteal and orbital abscesses, loss of
vision, cavernous sinus thrombosis, and brain abscesses.
Odontogenic orbital cellulitis is a relatively rare
complication, but it can cause blindness via rapidly
progressing tension orbit in spite of antibiotic treatment or
by direct dissemination. Therefore even the simplest dental
problems require careful attention.
Financial & competing interest disclosure
The authors do not have any competing interests in any product/
procedure mentioned in this study. The authors do not have any financial
interests in any product / procedure mentioned in this study

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Case Report Sharma V et al
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