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Brain and ocular infections can be the worst and fatal consequences of sinonasal infections in immunomodulated or immunocompromised patients.We report a case of a 35-year-old female who received an allogenic hematopoietic stem cell transplantation for acute myeloid leukemia, suffering from maxillo-spheno-ethmoidal rhinosinusitis which was complicated by cavernous sinus thrombosis, orbital cellulitis, optic ischemia and cerebritis.

Purpose: Orbital inflammatory disease has been historically diagnosed with computed tomography (CT) and magnetic resonance imaging (MRI). Orbital ultrasound has served as a non-radiation alternative that has been successful at diagnosing many orbital pathologies but is not commonly used in clinical practice due to need for specialized ultrasound training and equipment needs. We demonstrate use of handheld ultrasound for detecting orbital inflammation. Observations: We present five patients with orbital inflammation where a handheld ultrasound probe was able to capture features consistent with concurrent CT scans. Conclusions and importance: Handheld ultrasound is an accessible and portable method that can assist in the diagnosis and monitoring of orbital pathology.

Purpose: To present a rare case of late-onset Pseudomonas aeruginosa orbital cellulitis following glaucoma drainage device (GDD) implantation due to suture erosion. Observations: A 65-year-old male with a history of aphakic glaucoma and two remote prior glaucoma drainage device (GDD) surgeries of the right eye presented with right orbital signs. On examination, exposed securing Gore-Tex suture material over the plate of a GDD in the inferotemporal quadrant was present. Computed tomography (CT) scan demonstrated right orbital fat stranding, lateral rectus enlargement, and an intracapsular abscess consistent with orbital cellulitis. Cultures grew Pseudomonas aeruginosa. Treatment with intravenous and topical fortified antibiotics, incision and drainage of the abscess, and removal of the inferotemporal GDD was successful in resolving the infection. At post-operative month three, the patient underwent uncomplicated transscleral cyclophotocoagulation for further intraocular pressure control. Conclusions and Importance: Orbital cellulitis is an uncommon complication of GDD implantation, and typically occurs in the early post-operative period. To our knowledge, this is the first report of late-onset orbital cellulitis resulting from Pseudomonas aeruginosa, as well as the first case of GDD orbital cellulitis related to suture erosion.

Purpose: To describe a case of cilio-choroidal melanoma presenting as aseptic orbital cellulitis with massive conjunctival chemosis. Methods: Case report. Results: A 51-year-old man with a left retro-iris pigmented lesion had acute lid edema, conjunctival chemosis, and extensive hyphema. Ultrasound revealed a large, lobulated, wide-base choroidal-starting lesion affecting the ciliary bodies and vitreous chamber. MRI revealed low-intermediate T2-signal and intermediate-high T1-signal, with substantial post-contrastographic enhancement. After one week of systemic corticosteroids, the chemosis reduced significantly, and the patient was referred for enucleation, even without histologic confirmation. Post-surgical histopathology found 90% necrotic tissue, few viable cells, and no scleral or vascular invasion, with genetic analysis showing monosomy of chromosome 3 and 8q gain. Conclusion: Choroidal melanoma, particularly if necrotic, may occasionally present as aseptic orbital cellulitis, even without extraocular spread.

Introduction: The standard management of orbital cellulitis is to administer a combination of intravenous broad-spectrum antibiotics along with treatment of associated sinusitis. Objective: The purpose of this study was to evaluate whether the addition of corticosteroids could lead to earlier resolution of inflammation and improve disease outcome. Methods: We independently searched five databases (PubMed, SCOPUS, Embase, the Web of Science, and the Cochrane database) for studies published as recent as December 2019. Of the included studies, we reviewed orbital cellulitis and disease morbidity through lengths of hospitalization, incidence of surgical drainage, periorbital edema, vision, levels or C-reactive protein, and serum WBC levels in order to focus on comparing steroid with antibiotics treated group and only antibiotics treated group. Results: Lengths of hospitalization after admission as diagnosed as orbital cellulitis (SMD = −4.02 [−7.93; −0.12], p-value = 0.04, I2 = 96.9%) decrease in steroid with antibiotics treated group compared to antibiotics only treated group. Incidence of surgical drainage (OR = 0.78 [0.27; 2.23], p-value = 0.64, I2 = 0.0%) was lower in the steroid with antibiotics treated group compared to the antibiotics only treated group. Conclusion: Use of systemic steroids as an adjunct to systemic antibiotic therapy for orbital cellulitis may decrease orbital inflammation with a low risk of exacerbating infection. Based on our analysis, we concluded that early use of steroids for a short period can help shorten hospitalization days and prevent inflammation progression.

Background: Orbital cellulitis is a potentially life-threatening infection of the soft tissues surrounding the eye. Prompt diagnosis and treatment is crucial in mitigating damage to the delicate structures of the globe and orbit. Appropriate imaging is a key diagnostic tool and useful in differentiating from less severe infections such as preseptal cellulitis. Case: A 72 year old male with medical history notable for hypertension, hypothyroidism, and recently diagnosed multiple myeloma presented to the emergency department due to 3 days of right eye pain with associated swelling, erythema, and discharge. Point of Care Ultrasound (POCUS) performed in the Emergency Department was notable for peri-ocular fluid collection and edema, increasing suspicion for orbital cellulitis. Given the ultrasound findings, the patient was given intravenous antibiotics and was expedited for a contrast enhanced computed tomography (CT) scan of the orbit which demonstrated extraconal and intraconal fat stranding, confirming the diagnosis. The patient was treated with IV antibiotics and steroids and was discharged after an 11-day hospital admission with instructions to complete a 14-day course of antibiotics and 15-day taper of oral steroids. Why should an emergency physician be aware of this: To improve treatment outcomes and decrease the risk of vision loss, orbital cellulitis must be quickly diagnosed. A CT scan of the orbits is currently the gold standard in diagnosis, though in resource limited environments this imaging modality may not be readily available. Here, we present a typical case of orbital cellulitis in which POCUS was a useful tool in narrowing the diagnosis and ensuring prompt management of the infection.

Sinusitis is a common condition that can lead to various neurological complications due to the spread of infection to the intracranial and orbital regions. Fortunately, the availability of antibiotics has significantly improved the prognosis of sinusitis-associated intracranial complications. As a result, the overall incidence of neurological complications arising from sinusitis remains low. We present a rare case of a 13-year-old male who developed epidural empyema and orbital cellulitis as a complication of acute sinusitis. The patient initially exhibited signs and symptoms of orbital cellulitis, including eyelid swelling, erythema, and pain. Subsequently, the patient's condition worsened, with the development of fever and an intensifying headache. Imaging revealed an epidural empyema, necessitating urgent medical intervention. This case highlights the importance of early recognition and prompt management of sinusitis-related intracranial and orbital complications to prevent potentially life-threatening outcomes., (© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.)

Background: The diagnosis of coronavirus disease (COVID-19) is based on detecting viral RNA of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the nasal cavities and the nasopharynx. Millions of nasopharyngeal swab tests are currently performed daily worldwide; complications of the procedure are uncommon, but occasionally they occur. Case report: We describe the case of a 79-year-old man who developed right orbital cellulitis after a nasopharyngeal swab test for SARS-CoV-2. He underwent two surgeries for nasal polyposis 20 and 15 years prior, that probably caused an easy pathway to the medial wall of the orbit. At hospital admission he presented right visual loss, proptosis, palpebral edema, conjunctival chemosis, and limitations in eye movements. Computed tomography showed violation of the lamina papyracea, which appeared related to misdirection of the nasopharyngeal swab. He received intensive antibiotic treatment and achieved complete resolution of the orbital infection. To our knowledge this is the first case report concerning this dangerous complication. Conclusion: Orbital cellulitis is a serious condition that requires prompt diagnosis and treatment, as it may result in permanent visual loss or life-threatening complications, such as intracranial abscess and cavernous sinus thrombosis, if inadequately treated. This case highlights the importance of providing adequate instruction about nasal anatomy to health care professionals performing nasopharyngeal swab tests to avoid misdirections leading to potentially dangerous complications.

Wooden foreign bodies (FBs) within the orbit are difficult to diagnose both clinically and radiologically [1]. In acute settings, wood can be missed on standard computerized tomography (CT) due to its hypodense appearance which can be mistaken for air. If left undetected, wood fragments impose a significant risk of infection [2]. Therefore, its prompt removal, particularly from the head and neck region, is essential.Our case describes a 31-year-old man who presented with a clinical picture of orbital cellulitis post trauma, who was later found to have a large retained fragment of wood, initially undetected on CT orbits.

Brain and ocular infections can be the worst and fatal consequences of sinonasal infections in immunomodulated or immunocompromised patients. We report a case of a 35-year-old female who received an allogenic hematopoietic stem cell transplantation for acute myeloid leukemia, suffering from maxillo-spheno-ethmoidal rhinosinusitis which was complicated by cavernous sinus thrombosis, orbital cellulitis, optic ischemia and cerebritis., (© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.)

Purpose: This is a case report of an unusual case of the family transmission of Streptococcus pyogenes infection in three siblings. One brother contracted the infection which resulted in orbital cellulitis of two of his siblings, in the absence of anatomical or immunological predisposing factors. Observations: A young boy contracted an uncomplicated S pyogenes upper respiratory tract infection. The twin brother closely followed by the older sister both developed a S pyogenes orbital cellulitis a couple of days later. Conclusions and importance: To our knowledge, this is the first case ever reported of family transmission of orbital cellulitis. This highlights the importance of early diagnosis and treatment of S pyogenes, and the role of throat cultures as means of diagnosis even in the absence of symptoms or signs of pharyngitis.

Purpose: To report two cases of eyeball tattoos with short-term post procedural complications. Observations: Case 1 is a 26-year-old Mexican man that developed orbital cellulitis and posterior scleritis 2 h after an eyeball tattoo. Patient responded satisfactorily to systemic antibiotic and corticosteroid treatment. Case 2 is a 17-year-old Mexican man that developed two sub-episcleral nodules in the ink injection sites immediately after the procedure. Conclusions and importance: Eyeball tattoos are performed by non-ophthalmic trained personnel. There are a substantial number of short-term risks associated with this procedure. Long-term effects on the eyes and vision are still unknown, but in a worst case scenario could include loss of vision or permanent damage to the eyes.

Background: Orbital cellulitis is an infrequent but serious infectious complication of rhinosinusitis, most commonly seen in the pediatric population. Extension into the cavernous sinus, leading to further infection and thrombosis, is a rare but life-threatening complication. Although COVID-19 has been linked to an increased risk of venous thromboembolism, most cases involve extremity deep venous thrombosis or pulmonary embolism; reports of intracranial or jugular system thrombosis are rare., Case Report: We describe a case of a 17-year-old female patient with no significant medical history or thrombotic risk factors found to have orbital cellulitis and severe pansinusitis, complicated by multiple venous thromboses in the head and neck requiring emergent surgical intervention and pediatric intensive care admission. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Extensive head and neck venous thrombosis and intracranial abscesses are rare complications of pansinusitis and orbital cellulitis, and the thrombotic complications of COVID-19 are well documented. A delay in diagnosis and treatment can lead to potentially devastating consequences., (Published by Elsevier Inc.)

Purpose: To investigate the prevalence and magnetic resonance imaging (MRI) phenotype of retinoblastoma-associated orbital cellulitis. Additionally, this study aimed to identify postlaminar optic nerve enhancement (PLONE) patterns differentiating between inflammation and tumor invasion., Design: A monocenter cohort study assessed the prevalence of orbital cellulitis features on MRI in retinoblastoma patients. A multicenter case-control study compared MRI features of the retinoblastoma-associated orbital cellulitis cases with retinoblastoma controls., Participants: A consecutive retinoblastoma patient cohort of 236 patients (311 eyes) was retrospectively investigated. Subsequently, 30 retinoblastoma cases with orbital cellulitis were compared with 30 matched retinoblastoma controls without cellulitis., Methods: In the cohort study, retinoblastoma MRI scans were scored on presence of inflammatory features. In the case-control study, MRI scans were scored on intraocular features and PLONE patterns. Postlaminar enhancement patterns were compared with histopathologic assessment of postlaminar tumor invasion. Interreader agreement was assessed, and exact tests with Bonferroni correction were adopted for statistical comparisons., Main Outcome Measures: Prevalence of retinoblastoma-associated orbital cellulitis on MRI was calculated. Frequency of intraocular MRI features was compared between cases and controls. Sensitivity and specificity of postlaminar optic nerve patterns for detection of postlaminar tumor invasion were assessed., Results: The MRI prevalence of retinoblastoma-associated orbital cellulitis was 6.8% (16/236). Retinoblastoma with orbital cellulitis showed significantly more tumor necrosis, uveal abnormalities (inflammation, hemorrhage, and necrosis), lens luxation (all P < 0.001), and a larger eye size (P = 0.012). The inflammatory pattern of optic nerve enhancement (strong enhancement similar to adjacent choroid) was solely found in orbital cellulitis cases, of which none (0/16) showed tumor invasion on histopathology. Invasive pattern enhancement was found in both cases and controls, of which 50% (5/10) showed tumor invasion on histopathology. Considering these different enhancement patterns suggestive for either inflammation or tumor invasion increased specificity for detection of postlaminar tumor invasion in orbital cellulitis cases from 32% (95% confidence interval [CI], 16-52) to 89% (95% CI, 72-98)., Conclusions: Retinoblastoma cases presenting with orbital cellulitis show MRI findings of a larger eye size, extensive tumor necrosis, uveal abnormalities, and lens luxation. Magnetic resonance imaging contrast-enhancement patterns within the postlaminar optic nerve can differentiate between tumor invasion and inflammatory changes., (Copyright © 2022 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine the value of clinical features for advanced intraocular retinoblastoma as defined by the eighth edition of the American Joint Committee on Cancer (AJCC) cT3 category and AJCC Ophthalmic Oncology Task Force (OOTF) Size Groups to predict the high-risk pathologic features., Design: International, multicenter, registry-based retrospective case series., Participants: Eighteen ophthalmic oncology centers from 13 countries over 6 continents shared evaluations of 942 eyes enucleated as primary treatment for AJCC cT3 and, for comparison, cT2 retinoblastoma., Methods: International, multicenter, registry-based data were pooled from patients enrolled between 2001 and 2013. High-risk pathologic features were defined as AJCC categories pT3 and pT4. In addition, AJCC OOTF Size Groups were defined as follows: (1) less than half, (2) more than half but less than two thirds, (3) more than two thirds of globe volume involved, and (4) diffuse infiltrating retinoblastoma., Main Outcome Measures: Statistical risk of high-risk pathologic features corresponding to AJCC cT3 subcategories and AJCC OOTF Size Groups., Results: Of 942 retinoblastoma eyes treated by primary enucleation, 282 (30%) showed high-risk pathologic features. Both cT subcategories and AJCC OOTF Size Groups (P < 0.001 for both) were associated with high-risk pathologic features. On logistic regression analysis, cT3c (iris neovascularization with glaucoma), cT3d (intraocular hemorrhage), and cT3e (aseptic orbital cellulitis) were predictive factors for high-risk pathologic features when compared with cT2a with an odds ratio of 2.3 (P = 0.002), 2.5 (P = 0.002), and 3.3 (P = 0.019), respectively. Size Group 3 (more than two-thirds globe volume) and 4 (diffuse infiltrative retinoblastoma) were the best predictive factors with an odds ratio of 3.3 and 4.1 (P < 0.001 for both), respectively, for high-risk pathologic features when compared with Size Groups 1 (i.e., < 50% of globe volume)., Conclusions: The AJCC retinoblastoma staging clinical cT3c-e subcategories (glaucoma, intraocular hemorrhage, and aseptic orbital cellulitis, respectively) as well as the AJCC OOTF Size Groups 3 (tumor more than two thirds of globe volume) and 4 (diffuse infiltrative retinoblastoma) both allowed stratification of clinical risk factors that can be used to predict the presence of high-risk pathologic features and thus facilitate treatment decisions., (Copyright © 2022 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background: Sight-threatening complications from retained orbital and intraocular foreign bodies are frequently reported in literature. Delays in diagnosis can result in severe complications, including choroidal neovascularization, infection, and irreversible vision loss. Therefore, it is imperative that emergency physicians consider the possibility of orbital and intraocular foreign bodies when evaluating patients with acute facial trauma., Case Report: A 91-year-old woman with a history of laser-treated glaucoma and cataracts presented to an outside emergency department after a ground-level fall. A maxillofacial noncontrast computed tomography scan showed no facial fractures or hemorrhage, but a 41 mm × 4 mm foreign body within the intraconal compartment of the right orbit was identified. The object was presumed to be an implanted glaucoma drainage device, and the patient was discharged without antibiotics. One day after discharge, the patient developed right periorbital swelling and erythema with increasing purulent discharge and skin thickening, ultimately requiring transfer to our facility for management of complex right orbital cellulitis, orbital compartment syndrome, and surgical foreign body removal. Despite globe exploration and surgical intervention, the patient developed a frozen globe with no light perception in the right eye. Why Should an Emergency Physician Be Aware of This? Subtle ophthalmologic emergencies such as sight-threatening foreign bodies can be challenging to diagnose on imaging, particularly with the advent of implantable ocular technology. When an orbital foreign body is discovered in the context of facial trauma, early ophthalmology consultation should be considered., (Copyright © 2022. Published by Elsevier Inc.)

Background: Ophthalmologic complaints are common in the emergency department. The utility of point-of-care ultrasound (POCUS) as an accessible, noninvasive modality to evaluate ocular pathology is of great value-particularly in settings where resources are limited or where ophthalmologic consultation may not be readily available., Case Report: A 21-year-old woman presented to the emergency department with periorbital edema, erythema, and drainage that was worsening despite topical and oral antimicrobial therapy. Mild proptosis was present on examination. POCUS was performed to investigate her symptoms further. A modified ocular ultrasound revealed prominence and edema of the retro-orbital soft tissue with echogenic fat, consistent with the diagnosis of orbital cellulitis. These findings were corroborated with computed tomography imaging. Why Should an Emergency Physician Be Aware of This?: Few reports describe the utility of POCUS in evaluating patients for orbital cellulitis. This case emphasizes the value of POCUS in assessing patients presenting to the emergency department with ocular complaints and demonstrates ultrasound-specific findings that may lead the clinician toward the diagnosis of orbital cellulitis. © 2021 Elsevier Inc., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Orbital cellulitis is an uncommon ophthalmological emergency in children, but rapid emergency department (ED) diagnosis is essential., Case Report: A 13-year-old boy presented to our pediatric ED with left orbital cellulitis secondary to pansinusitis. Emergency bedside ocular ultrasonography was used to evaluate and expedite his management. Besides inflammatory changes observed on ultrasound of his affected orbit, the patient had an elevated optic disc height and increased nerve sheath diameter, which were not commonly reported in published literature on orbital cellulitis. Emergent computed tomography of the orbits and head showed orbital cellulitis without complications of orbital abscess or cavernous sinus thrombosis. Despite initiating early appropriate antibiotics, there was rapid progression of his disease and he developed intraconal abscess and cavernous sinus thrombosis the following day. After emergency surgical drainage of his pansinusitis, antibiotics, and anticoagulation, he was discharged well after a 2-week hospitalization. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: There are important advantages of using bedside ultrasonography for diagnosis of pediatric orbital cellulitis in the ED setting. Further research should be done to evaluate the clinical significance of an enlarged optic nerve sheath diameter and raised optic disc height in pediatric orbital cellulitis., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Visual loss can be the result of an abnormality anywhere along the visual pathway including the globe, optic nerve, optic chiasm, optic tract, thalamus, optic radiations or primary visual cortex. Appropriate imaging analysis of visual loss is facilitated by a compartmental approach that establishes a differential diagnosis on the basis of suspected lesion location and specific clinical features. CT and MRI are the primary imaging modalities used to evaluate patients with visual loss and are often complementary in evaluating these patients. One modality may be preferred over the other depending on the specific clinical scenario. Depending on the pattern of visual loss and differential diagnosis, imaging coverage may require targeted evaluation of the orbits and/or assessment of the brain. Contrast is preferred when masses and inflammatory processes are differential considerations. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2018 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background: Cellulitis is a common clinical condition with low rates of morbidity and mortality if treated appropriately. Mimics of cellulitis presenting with erythema, edema, warmth, and pain can be associated with grave morbidity and mortality if misdiagnosed., Objective: This review investigates the signs and symptoms of cellulitis, mimics of cellulitis, and an approach to the management of both cellulitis and its mimics., Discussion: The current emergency medicine definition of cellulitis includes erythema, induration, warmth, and swelling. Given the common pathophysiologic pathways, cellulitis mimics often present in an analogous manner. These conditions include septic bursitis, septic joint, deep vein thrombosis, phlegmasia cerulea dolens, necrotizing fasciitis, flexor tenosynovitis, fight bite (closed fist injury), orbital cellulitis, toxic shock syndrome, erysipelas, abscess, felon, paronychia, and gouty arthritis. Many of these diseases have high morbidity and mortality if missed by the emergency physician. Differentiating these mimics from cellulitis can be difficult in the fast-paced emergency setting. A combination of history, physical examination, and focused diagnostic assessment may assist in correctly identifying the underlying etiology. For many of the high mortality cellulitis mimics, surgical intervention is necessary., Conclusion: Cellulitis and its mimics present similarly due to the same physiologic responses to skin and soft tissue infections. A combination of history, physical examination, and diagnostic assessment will help the emergency physician differentiate cellulitis from mimics. Surgical intervention is frequently needed for high morbidity and mortality mimics., (Published by Elsevier Inc.)

Diseases of the orbit can be categorized in many ways, but in this chapter we shall group them according to etiology. Inflammatory diseases of the orbits may be infectious or noninfectious. Of the infections, orbital cellulitis is the most common and typically arises as a complication of acute sinusitis. Of the noninfectious, inflammatory conditions, thyroid orbitopathy is the most common and results in enlargement of the extraocular muscles and proliferation of the orbital fat. Idiopathic orbital inflammatory syndrome is another cause of inflammation in the orbit, which may mimic thyroid orbitopathy or even neoplasm, but typically presents with pain. Masses in the orbit may be benign or malignant and the differential diagnosis primarily depends on the location of the mass lesion, and on the age of the patient. Lacrimal gland tumors may be lymphomas or epithelial lesions of salivary origin. Extraocular muscle tumors may represent lymphoma or metastases. Tumors of the intraconal fat are often benign, typically hemangiomas or schwannomas. Finally, globe tumors may be retinoblastomas (in children), or choroidal melanomas or metastases in adults., (© 2016 Elsevier B.V. All rights reserved.)