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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 217-219

A rare presentation of neonatal retrobulbar orbital abscess secondary to acute dacryocystitis


Department of Orbit, Oculoplasty and Ocular Oncology, Shri Sadguru Seva Sangh Trust, Chitrakoot, Madhya Pradesh, India

Date of Submission13-May-2021
Date of Acceptance24-Aug-2021
Date of Web Publication07-Jan-2022

Correspondence Address:
Dr. Gaurav Garg
Oculoplasty, Ocular Oncology and Facial Aesthetic Services, View Care - Vision and Eye Wellness Centre, New Delhi - 110091
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1210_21

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  Abstract 


Clinical presentation of a neonate with acute dacryocystitis may vary considerably. A retrobulbar orbital abscess secondary to pediatric acute dacryocystitis is extremely rare. Currently, the treatment of choice is a surgical intervention in view of the life-threatening condition. Our short report shows a 28-day-old neonate with bilateral pediatric acute dacryocystitis, preseptal cellulitis, and retrobulbar orbital abscess in the right eye. Radiological examination of the orbit showed bilateral lacrimal sac mucocele and intra-orbital large abscess in the right eye. A trial of medical management in the form of microbial culture and sensitivity-proven intravenous antibiotics were given because of parents' hesitancy toward surgical intervention. The neonate had a successful anatomic and functional outcome.

Keywords: Neonatal acute dacryocystitis, neonatal retrobulbar orbital abscess, pediatric acute dacryocystitis, retrobulbar orbital abscess, treatment of retrobulbar orbital abscess


How to cite this article:
Gabba HS, Garg G, Warkade RP, Agarwal A, Mehta A, Agarwal R. A rare presentation of neonatal retrobulbar orbital abscess secondary to acute dacryocystitis. Indian J Ophthalmol Case Rep 2022;2:217-9

How to cite this URL:
Gabba HS, Garg G, Warkade RP, Agarwal A, Mehta A, Agarwal R. A rare presentation of neonatal retrobulbar orbital abscess secondary to acute dacryocystitis. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Jan 19];2:217-9. Available from: https://www.ijoreports.in/text.asp?2022/2/1/217/334861



Congenital obstruction of the nasolacrimal duct (CNLDO) is the most common disorder of the lacrimal system in infants.[1] Pediatric acute dacryocystitis (PAD), however, is rare and occurs mostly as a complication of CNLDO. PAD is more common in neonates with female preponderance.[1] The classical presentation of PAD is tenderness and inflammation of the tissue overlying the lacrimal sac.[1] PAD is managed variably depending on its severity, where the management options include conservative treatment by intravenous broad-spectrum antibiotics, surgical probing, incision and drainage, and dacryocystorhinostomy.

PAD can potentially complicate as chronic dacryocystitis, preseptal cellulitis, and rarely it can present with posterior extension, resulting in orbital cellulitis or retrobulbar orbital abscess (ROA), though it is more often seen in the adult population.[2],[3],[4],[5] ROA presents with proptosis, chemosis, limitation of eye motility, or relative pupillary defect.[1]

Currently, there is sparse literature on ROA following PAD in neonates and a majority of them were managed surgically.[6] The present case is unique as it describes the successful anatomical and functional outcome with medical management in the same.


  Case Report Top


A 28-day-old neonate boy presented with a history of protrusion of the right eye for 6 days. He had no significant prenatal, natal, and postnatal history. Amid the third week since birth, he developed watering and mucopurulent discharge in both eyes. He was diagnosed as a case of CNLDO by his primary care physician and was treated with topical tobramycin 0.3% eye drops 4 times a day for 1 week and Crigler massage. A day after, his mother noticed redness and swelling of the upper and lower eyelids and protrusion of the right eye, followed by a fever which kept on increasing for the next 6 days till he was presented to our tertiary eye center. On presentation to our center, the neonate was found to have a temperature of 102 F. On examination, both eyes showed severe edema and erythema of both upper and lower eyelids with mucopurulent discharge on gentle pressure over the lacrimal sac. There was a marked proptosis and severe limitation of ocular movements in all directions of gazes in the right eye [Figure 1]a. Anterior and posterior segments of the right eye were unable to be evaluated due to the tight closure of the eyelids, whereas the left eye showed full and free extraocular motility with normal anterior and posterior segments.
Figure 1: (a) Clinical photography showing bilateral preseptal cellulitis and proptosis in the right eye. (b) Axial cuts of CT orbit showing bilateral lacrimal sac mucocele and a well-defined large soft tissue hyperdense lesion filling the orbit in infero-medial aspect indenting and displacing the globe and optic nerve laterally with proptosis in the right eye. (c) Coronal cuts of CT orbit showing bilateral preseptal swelling with the right eye more than the left eye. (d) Clinical photography showing resolution of bilateral inflammation and retrobulbar orbital abscess in the right eye after 3 months

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The lacrimal sac discharge sample was sent for microbial culture and sensitivity. The hematological evaluation showed raised erythrocyte sedimentation rate with normal blood counts. Computed tomography scan of the orbit revealed enlarged lacrimal sac suggestive of dacryocystocele in both eyes and a well-defined large soft tissue hyperdense lesion filling the orbit in infero-medial aspect indenting and displacing the globe and optic nerve laterally with proptosis in the right eye with no intranasal extension. It also showed bilateral preseptal swelling with the right eye more than the left eye. There was no evidence of infection in the paranasal sinus, or cavernous sinus [Figure 1]b and [Figure 1]c. The neonate was diagnosed with a neonatal retrobulbar orbital abscess in the right eye and preseptal cellulitis in the left eye secondary to pediatric acute dacryocystitis.

Given the vision and life-threatening nature of the disease, immediate surgical drainage of the right eye was advised. On account of the refusal by parents for surgical drainage, the neonate was given a trial of conservative management under guarded visual and life prognosis. The neonate was admitted and empirically treated with intravenous injections of cefotaxime 150 mg 4 times a day and amikacin 54 mg once a day along with topical eyedrops moxifloxacin 0.5% 4 times a day. Over the next 48 hours, the inflammatory signs decreased in both eyes with a significant reduction in proptosis of the right eye. Microbial culture and sensitivity demonstrated methicillin-sensitive Staphylococcus aureus. Following this, the neonate was continued on intravenous cefotaxime only for a total of 5 days and showed marked resolution of proptosis in the right eye and erythema and edema of the eyelids of both eyes. Extraocular motility of the right eye became full and free. The patient was discharged on oral amoxicillin/clavulanic acid 70 mg thrice a day and topical moxifloxacin 0.5% 4 times a day for 7 days along with Crigler massage. At a 3-month follow-up, there was a complete resolution of the retrobulbar orbital abscess with no signs of recurrence [Figure 1]d. The patient is followed at monthly intervals.


  Discussion Top


The clinical presentation of a neonate with CNLDO may vary considerably. The diagnosis of CNLDO is obvious from symptoms and is clinically confirmed by regurgitation on pressure over the lacrimal sac test. Fortunately, during the first year, 90%–95% of CNLDOs are resolved spontaneously or with conservative medical management, including antibiotics and massages.[7],[8] However, the rest are at an extremely high risk of developing PAD, which can further complicate as preseptal cellulitis, orbital cellulitis, and rarely retrobulbar orbital abscess.[1] The exact pathophysiology behind the development of ROA secondary to PAD is still unknown. But it is suspected that the anteroinferior anatomical location of the lacrimal sac, in the presence of dacryocystitis can lead to communication between medial and inferior rectus muscles directly into the intraconal space, thereby precipitating ROA.[9]

The ROA is an ophthalmic emergency, endangering vision and life by potential complications: vision loss, meningitis, thrombosis of the cavernous sinuses, and formation of brain abscesses which is treated by drainage.[10]

In previous reports, drainage of ROA has been performed through various approaches including incision over the lacrimal sac or orbitotomy as well as through endonasal access.[8],[10],[11] In the present case, due to the parents' reluctance to surgical intervention, a trial of medical management with intravenous antibiotics was given, which had a successful anatomical and functional outcome.


  Conclusion Top


To conclude, this case emphasizes the close monitoring and appropriate treatment of pediatric acute dacryocystitis, as they can progress to vision and life-threatening retrobulbar orbital abscess. In the case of the development of a retrobulbar orbital abscess, immediate surgical intervention and drainage are the treatment of choice. A trial of microbial culture and sensitivity-proven medical treatment can be an apt substitute if surgery is contraindicated with close monitoring.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ali MJ. Pediatric acute dacryocystitis. Ophthalmic Plast Reconstr Surg 2015;31:341-7.  Back to cited text no. 1
    
2.
Ataullah S, Sloan B. Acute dacryocystitis presenting as an orbital abscess. Clin Exp Ophthalmol 2002;30:44-6.  Back to cited text no. 2
    
3.
Ntountas I, Morschbacher R, Pratt D, Patel BC, Anderson RL, McCann JD. An orbital abscess secondary to acute dacryocystitis. Ophthalmic Surg Lasers 1997;28:758-61.  Back to cited text no. 3
    
4.
Mauriello JA, Wasserman BA. Acute dacryocystitis: An unusual cause of life-threatening orbital intraconal abscess with frozen globe. Ophthalmic Plast Reconstr Surg 1996;12:294-5.  Back to cited text no. 4
    
5.
Kikkawa DO, Heinz GW, Martin RT, Nunery WN, Eiseman AS. Orbital cellulitis and abscess secondary to dacryocystitis. Arch Ophthalmol 2002;120:1096-9.  Back to cited text no. 5
    
6.
Al-Salem KM, Alsarayra FA, Somkawar AR. Neonatal orbital abscess. Indian J Ophthalmol 2014;62:354-7.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Petersen RA, Robb RM. The natural course of congenital obstruction of the nasolacrimal duct. J Pediatr Ophthalmol Strabismus 1978;15:246-50.  Back to cited text no. 7
    
8.
Juul-Dam M, Laursen C, Wiboe L, Hertz B, Bille J, Næser K. Bilateral dacryocystitis complicated by unilateral retrobulbar abscess in a five-week-old infant. Orbit 2020;39:209-11.  Back to cited text no. 8
    
9.
Alsalamah AK, Alkatan HM, Al-Faky YH. Acute dacryocystitis complicated by orbital cellulitis and loss of vision: A case report and review of the literature. Int J Surg Case Rep 2018;50:130-4.  Back to cited text no. 9
    
10.
Mohan ER, Chandravanshi SCL, Udhay P. Retrobulbar orbital abscess secondary to dacryocystitis in a neonate. Ophthalmic Plast Reconstr Surg 2007;23:238-40.  Back to cited text no. 10
    
11.
Weiss GH, Leib ML. Congenital dacryocystitis and retrobulbar abscess. J Pediatr Ophthalmol Strabismus 1993;30:271-2.  Back to cited text no. 11
    


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