Successful management of sub-Tenon's abscess in an adult after strabismus surgery: A case report

Subhash Dadeya; Himshikha Aggarwal

doi:10.4103/ijo.IJO_1822_22

CASE REPORT

Year : 2023 | Volume : 3 | Issue : 2 | Page : 490-492

Successful management of sub-Tenon's abscess in an adult after strabismus surgery: A case report

Subhash Dadeya¹, Himshikha Aggarwal²
¹ Department of Ophthalmology, Guru Nanak Eye Centre, New Delhi, India
² Guru Nanak Eye Centre, New Delhi, India

Date of Submission	25-Jul-2022
Date of Acceptance	20-Mar-2023
Date of Web Publication	28-Apr-2023

Correspondence Address:
Himshikha Aggarwal
29, North Avenue Road, West Punjabi Bagh, New Delhi - 110 026
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1822_22

Abstract

Periocular and orbital infections post-strabismus surgery are uncommon, with most of these cases reported in children. We report a rare case of sub-Tenon's abscess in a 27-year-old female following strabismus surgery, which was successfully managed with systemic and topical antibiotics without any requirement for surgical drainage of the abscess.

Keywords: Adult, complications of strabismus surgery, postoperative infections, sub-Tenon's abscess

How to cite this article:
Dadeya S, Aggarwal H. Successful management of sub-Tenon's abscess in an adult after strabismus surgery: A case report. Indian J Ophthalmol Case Rep 2023;3:490-2

How to cite this URL:
Dadeya S, Aggarwal H. Successful management of sub-Tenon's abscess in an adult after strabismus surgery: A case report. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Jun 10];3:490-2. Available from: https://www.ijoreports.in/text.asp?2023/3/2/490/374907

Postoperative infection following strabismus surgery, although rare, can be a potentially site-threatening complication. These infections can involve any periocular structure and present as conjunctivitis, infected epithelial inclusion cyst, subconjunctival or sub-Tenon's abscess, keratitis, preseptal or orbital cellulitis, uveal effusion syndrome, or even endophthalmitis.^[1],[2] We hereby report a case of a 27-year old female who developed sub-Tenon's space infection post-strabismus surgery.

Case Report

A 27-year-old female was examined in our strabismus department for esotropia with superior oblique palsy and amblyopia in the left eye. Her best corrected visual acuity was 20/20 OD and 20/40 OS. A 45 prism-diopter (PD) esotropia in the left eye with grade 2 inferior oblique overaction (20 PD) was found on further examination. She did not exhibit any systemic illness and was in good health.

Surgery was performed under local (peribulbar) anesthesia. The eyelids and the surrounding area were thoroughly cleaned with povidone iodine 5%, along with instillation of the same in both fornices before starting surgery. The patient underwent 6 mm medial rectus recession (hemi-hangback technique) and 8 mm lateral rectus resection through a fornix-based approach, along with 10 mm inferior oblique recession. The muscles were fixated to sclera using 6-0 absorbable sutures (Vicryl, polyglactin 910), while conjunctival closure was performed with 8-0 absorbable sutures (Vicryl, polyglactin 910). The patient was examined and discharged on the first postoperative day on oral antibiotics (ciprofloxacin 500 mg, twice a day), topical antibiotic (tobramycin 0.3%), and topical steroids (dexamethasone 0.1%), each to be administered six times a day.

On the 10^th postoperative day, the patient presented to the emergency with intense pain, redness, and discharge in the left eye [Figure 1]. Examination revealed lid swelling with conjunctival hyperemia and chemosis with localized collection of pus discharging through the conjunctiva. Sutures at the conjunctival incision site were intact, and there was no reaction in the anterior chamber. Patient was orthophoric on examination, with no limitation or restriction of extraocular movements. The right eye was within normal limits, and there was no drop in vision in either eye with normal fundus.

Figure 1: Postoperative day 10 image showing left upper and lower lid swelling with conjunctival chemosis and pus discharge from a sub-Tenon's abscess

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The patient was diagnosed as having a sub-Tenon's abscess. Pus from the wound site was sent for culture and sensitivity, and the patient was admitted in our in-patient department for intravenous antibiotics. She was started on intravenous ceftriaxone 1 g twice a day, intramuscular gentamycin 60 mg twice a day, along with fortified cefazolin 5% drops every two hourly, fortified tobramycin 1.4% drops two hourly, a cycloplegic (ointment atropine 1% once at night time), and tobramycin ointment 0.3%. Oral analgesics were given to combat pain. Both swelling and pus collection showed significant reduction after 3 days of treatment [Figure 2] and the patient did not require drainage of the abscess. Culture and sensitivity report revealed Staphylococcus aureus sensitive to cefoxitin, erythromycin, vancomycin, clindamycin, and gentamycin. Antibiotics were hence switched to fortified vancomycin 5% drops six times a day and fortified gentamycin 1.3% drops six times a day. On the 17^th postoperative day, conjunctival sutures were found to be loose [Figure 3] and hence removed along with irrigation of the wound site with cefazolin (500 mg/2 ml) and gentamycin (40 mg/2 ml). On discharge, there was marked reduction in conjunctival erythema with resolution of lid swelling and abscess [Figure 4]. In subsequent postoperative visits, all signs and symptoms resolved and the patient was orthophoric with normal extraocular movements.

Figure 2: Postoperative day 14 image showing a decrease in lid swelling and abscess size

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Figure 3: Postoperative day 18 image with marked decrease in conjunctival chemosis and resolution of the sub-Tenon's abscess

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Figure 4: Postoperative day 21 image after removal of conjunctival sutures

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Discussion

Periocular and orbital infections following strabismus surgery are uncommon with an estimated incidence between one in 1100 and one in 1900 cases.^[3],[4],[5] Although majority of the cases are unilateral and resolve fully with systemic antibiotics and surgical drainage/debridement when indicated, cases of bilateral orbital cellulitis and poor visual outcomes have been reported.^[6] These infections can also weaken the tendon, allowing the suture to cheese wire through a friable tendon, resulting in a lost muscle.^[2],[7] Hence, this calls for prompt diagnosis and aggressive treatment of all such infections to prevent further complications.

Patients usually present within 2–8 days^{[1],[2],[6],[8],[9]} of strabismus surgery with conjunctival erythema, mucopurulent discharge, periorbital and lid edema, pain with eye movements, fever, and fatigue. Potential risk factors include age under 18 years, developmental delay, immune compromise, preceding nonocular infections including sinusitis, recurrent acute otitis media, mastoiditis, excessive eye rubbing, and poor hygiene.^[5],[6] Limbal incisions and resurgeries are also associated with an increased likelihood of developing postoperative infections.^[10] None of these predisposing factors were identified in our patient on re-examination.

The common causative organisms in order of their occurrence include Sta. aureus, Staphylococcus epidermidis, Streptococcus pneumoniae, and Haemophilus influenzae,^[5] which is in concordance with our case where Sta. aureus was isolated.

Our patient received both povidone iodine 5% instillation in the fornices as well as antibiotic–steroid eye drops in the postoperative period as prophylactic measures against infection. Koederitz et al.^[10] have, however, demonstrated prophylactic single-dose povidone iodine following strabismus surgery to be noninferior to antibiotic–steroid drops for preventing infection.

A higher incidence of post-strabismus surgery infections has been reported in children,^[5],[9] likely due to multifactorial causes, with most requiring surgical drainage for the abscess. To the best of our knowledge, this is a rare case of sub-Tenon's abscess in an adult, which was managed without any surgical intervention.

Conclusion

In conclusion, having a high index of suspicion, prompt microbial culture and sensitivity, along with use of appropriate antibiotics are paramount in the successful management of infections post-strabismus surgery.

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.

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