July 2014 817 Brief Communications

Cite this article as: Ajay K, Krishnaprasad R. Feedback of final year

ophthalmology postgraduates about their residency ophthalmology training
in South India. Indian J Ophthalmol 2014;62:814-7.
Source of Support: Nil. Confict of Interest: None declared.
Orbital cellulitis in a neonate of the
tooth bud origin : A case report
Poonam Lavaju, Badri Prasad Badhu,
Basudha Khanal
1
, Bhuwan Govinda Shrestha
Orbital cellulitis is a serious, yet uncommon infection in
neonates. It can result in signifcant sight and life threatening
complications. Most commonly, it occurs secondarily as the
result of a spread of infection from the sinuses. Orbital cellulitis,
secondary to dental infection is rare. We hereby report a case of
orbital cellulitis secondary to dental infection in a 15-day-old
neonate without any systemic features.
Key words: Odontogenic orbital cellulitis, orbital cellulites, tooth
bud abscess
Orbital cellulitis in neonates is a potentially lethal condition
that can result in significant complications including
blindness, cavernous sinus thrombosis, meningitis, subdural
emphysema and brain abscess.
[1]
Orbital cellulitis is
usually a complication of infection in the paranasal sinuses
(60-80%)
[2,3]
and is infrequently the result of an infection of
dental origin (2-5%).
[4,5]
To our knowledge only one case of a neonate with orbital
cellulitis secondary to dental infection has been reported. We
hereby report a case of orbital cellulitis in a 15-day-old neonate
without systemic features, secondary to the tooth bud abscess.
Case Report
A 15-day-old female neonate patient was brought with
history of a sudden onset proptosis of the lef eye for three
days. There was no history of trauma, fever or any systemic
complaints. She was delivered normally at full term without
any signifcant antenatal or postnatal complications. She was
exclusively breastfed. Vital signs including pulse, temperature,
and respiratory rate were within normal limits.
Ocular examination revealed an axial proptosis of the lef
eye with limited ocular movements in all directions [Fig. 1].
The lef eyelid was swollen and infamed. Anterior segment
examination was normal. Pupillary reaction and fundus
examination were also normal. The right eye was normal.
Systemic examination revealed no abnormalities except the
presence of a tooth bud abscess in the lef maxillary alveolar
ridge with overlying facial swelling [Fig. 2].
Hematological investigations showed the following
results: Hemoglobin- 14.5 gm%, PCV- 57.4%, total leucocyte
count- 17,000/mm
3
, neutrophils- 52%, lymphocytes- 48%,
platelet count- 483,000/mm
3
, urea- 28 mg/dl, creatinine-
0.8 mg/dl. Microbiological examination of the urine was
normal. Blood and urine culture revealed no organisms.
Microbiological investigation of both conjunctival and
oral swabs grew Staph aureus that was sensitive to amikacin,
vancomycin, ofoxacin, gentamicin, cefotaxime, co-trimoxazole
and resistant to penicillin and cefalexin.
CT scan of the head and orbit showed a dense sof tissue
Department of Ophthalmology,
1
Department of Microbiology,
B.P. Koirala Institute of Health Sciences, Dharan, Nepal
Correspondence to: Dr. Poonam Lavaju, Associate Professor,
Department of Ophthalmology, B. P. Koiral Institute of Health Sciences,
Dharan, Nepal. E-mail: drpoonamlavaju @yahoo.com
Manuscript received: 18.08.13; Revision accepted: 11.02.14
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DOI:
10.4103/0301-4738.138296

Issue 5 (September-October 2008), authored by Parikshit
Gogate, Madan Deshpande and Sheetal Dharmadhikari.
Thank you for your kind co-operation.
References
1. Grover AK. Postgraduate ophthalmic education in India: Are we
on the right track? Indian J Ophthalmol 2008;56:3-4.
2. Thomas R, Dogra M. An evaluation of medical college departments
of ophthalmology in India and change following provision of
modern instrumentation and training. Indian J Ophthalmol
2008;56:9-16.
3. Gogate PM, Deshpande MD. The crisis in ophthalmology residency
training programs. Indian J Ophthalmol 2009;57:74-5.
4. Murthy GV, Gupta SK, Bachani D, Sanga L, John N, Tewari HK.
Status of speciality training in ophthalmology in India. Indian J
Ophthalmol 2005;53:135-42.
5. Gogate P, Deshpande M, Dharmadhikari S. Which is the
best method to learn ophthalmology? Resident doctors
perspective of ophthalmology training. Indian J Ophthalmol
2008;56:409-12.
6. Mostafaei A, Hajebrahimi S. Perceived satisfaction of ophthalmology
residents with the current Iranian ophthalmology curriculum. Clin
Ophthalmol 2011;5:1207-10.
7. Rogers GM, Oetting TA, Lee AG, Grignon C, Greenlee E,
Johnson AT, et al. Impact of a structured surgical curriculum on
ophthalmic resident cataract surgery complication rates. J Cataract
Refract Surg 2009;35:1956-60.
8. Zhou AW, Noble J, Lam WC. Canadian ophthalmology residency
training: An evaluation of resident satisfaction and comparison
with international standards. Can J Ophthalmol 2009;44:540-7.
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818 IndianJournalofOphthalmology Vol. 62 No. 7
lesion of size 2.5 1.2 cm in the extraconal space of the lef orbit
and pre-septal region causing anterolateral displacement of the
globe. Recti muscles were not clearly visualized on CT scan.
The sinuses were normal. The fndings were suggestive of the
lef orbital cellulitis [Fig. 3].
The neonate was admited and administered intravenous
injections of vancomycin of 60 mg/kg/per day in two divided
doses with amikacin of 20 mg/kg three times daily and oral
metronidazole of 25 mg/kg/three times daily for 14 days. The tooth
bud abscess improved with this conservative management. Within
24 hours of the initiating treatment, there was an improvement
in extraocular movements and decreased proptosis. The patient
was discharged afer two weeks and prescribed Augmentin syrup
for another two weeks. At one month of follow-up, the condition
of the neonate was much improved with no proptosis and full
extra-ocular movements. [Fig. 4a and b]
Discussion
Orbital cellulitis is a rare, but potentially lethal condition
in children that has been occasionally reported in infants.
[1]

At maximum, ten cases of infants have been reported in the
literature.
[6-10]
Orbital cellulitis due to dental infection has been reported
in children and adults, but only one case has been reported in
a neonate.
[4,5]
Laura et al., reported a 24-day-old neonate with
orbital cellulitis accompanied by a sub-periosteal abscess of
the dental origin.
[7]
Dolter et al., reported a case of orbital cellulites in a
one-month-old secondary to ethmoidal sinusitis.
[8]
Harris reported
a case of orbital cellulitis in a one-week-old secondary to septic
thrombophlebitis from an intravenous line in a scalp vein.
[9]
Tanuja A et al., reported the same in a nine-day-old neonate
with septic arthritis of the left ankle joint and ethmoidal
sinusitis.
[10]
Most of the previously reported cases presented with
systemic features that were absent in our case.
The patient could have acquired the infection through a
contaminated nipple during the breastfeeding, which then
spread to a labial ulcer or prominent tooth bud on the lef side.
The infection could have then tracked subperiosteally and
Figure 1: Left eye proptosis with orbital cellulitis
Figure 2: Showing tooth bud with abscess in left alveolar maxillary area
Figure 3: Soft tissue density lesion of size 25 12 mm in extraconal
space in the left orbit and pre-septal region causing anterolateral
displacement of globe. Features suggestive of the left eye orbital
cellulitis with pockets of abscess formation
Figure 4: Follow-up at one month (a) Decrease in proptosis (b) neonatal
tooth with no abscess
b a
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July 2014 819 Brief Communications
entered the sof tissue, causing orbital cellulitis with abscess
formation.
[7]
The management of orbital cellulitis in neonate
and infants is challenging and must be treated urgently so as
to prevent more serious complications.
In the presence of a dental abscess, the treatment with
medication alone is usually insufcient. It is necessary to
remove the source of infection, which can be achieved through
abscess drainage. Antibiotic treatment of orbital cellulitis
should include broad spectrum coverage against both aerobic
and anerobic organisms, including oral pathogens.
[4,5]
In this
case, Staph aureus was present in both infection sites. However,
the patient showed signifcant improvement with medical
management alone within 24 hours of initiating antibiotic
treatment.
While conservative treatment was used in this case,
Harris protocol calls for emergent drainage of the abscess
if vision is compromised and urgent drainage (within 24
hours) of large abscesses causing pain, superior or inferior
extension, intracranial infection, or those of anaerobic or
dental origin.
[9]
In the case reported by Laura et al., the condition of the baby
worsened and proptosis increased with medical management
alone, therefore surgical decompression and subsequent sinus
drainage became necessary.
[7]
Fortunately, our patient showed
improvement with medical management alone. However,
had our patients condition worsened, surgical removal of the
abscess would have been necessary.
In conclusion, orbital cellulitis can be present in the absence
of typical systemic features. A complete examination of the
oral cavity to determine the dental origin of infection should
be carried out. Regardless of the patients age, early diagnosis
and prompt treatment with proper antibiotics coverage can
result in a good prognosis for the patient.
References
1. Jain A, Rubin PA. Orbital cellulitis in children. Int Ophthalmol Clin
2001;41:71-86.
2. Sinus allergy health partnership. Antimicrobial treatment
guidelines for acute bacterial rhinosinusitis. Otolaryngol Head
Neck Surg 2004;130 Suppl:S1-45.
3. Jackson K, Baker SR. Clinical implication of orbital cellulites.
Laryngoscope 1986;96:569-74.
4. Caruso PA, Watkins LM, Suwansaard P, Yamamoto M,
Durand ML, Romo LV, et al. Odontogenic orbital infammation:
Clinical and CT findings-initial observations. Radiology
2006;239:187-94.
5. Stone A, Straitigos GT. Mandibular odontogenic infection
with serious complication. Oral Surg Oral Med Oral Pathol
1979;47:395-400.
6. Mallika PS, Tan AK, Aziz S, Vanitha R, Tan TY, Faisal HA. Orbital
Cellulitis complicated by subperiosteal abscess in a neonate with
ethmoiditis. HK J Paediatr 2009;14:275-8.
7. Green LK, Mawn LA. Orbital cellulitis secondary to tooth bud abscess
in a neonate. J Pediatr Ophthalmol Strabismus 2002;39:358-61.
8. Dolter J, Wong J, Janda JM. Association of Neisseria cinerea with
ocular infections in paediatric patients. J Infect 1998;36:49-52.
9. Harris GJ. Subperiosteal abscess of the orbit. Arch Ophthalmol
1983;101:751-7.
10. Abhilash T, Krishnappa P, Guha J, Jayaram T, Krishnamurthy D.
Methicillin resistant Staphylococcus aureus [MRSA] orbital cellulitis
in a nine -day-old neonate: A case report. Int J Curr Sci Res
2011;1:194-7.
Cite this article as: Lavaju P, Badhu BP, Khanal B, Shrestha BG. Orbital
cellulitis in a neonate of the tooth bud origin : A case report. Indian J Ophthalmol
2014;62:817-9.
Source of Support: Nil. Confict of Interest: None declared.
Combined special capsular tension
ring and toric IOL implantation for
management of post-DALK high
regular astigmatism with subluxated
traumatic cataract
Asim Kumar Kandar
We report a case of 18-year-old male who has undergone
phacoemulsifcation with implantation of toric IOL (AcrySof IQ
SN6AT9) afer fxation of lens capsule with Cionnis capsular
tension ring (CTR) for subluxated traumatic cataract with high
astigmatism afer deep anterior lamellar keratoplasty (DALK).
He underwent right eye DALK for advanced keratoconus four
years earlier. He had history of trauma one year later with
displaced clear crystalline lens into anterior chamber and
graf dehiscence, which was repaired successfully. The graf
survived, but patient developed cataract with subluxated
lens, for which phacoemulsifcation with implantation of toric
IOL was done. Serial topography showed regular corneal
astigmatism of -5.50 diopter (K
1
42.75 D @130, K
2
48.25 D
@40). At 10-month follow-up, the patient has BCVA 20/30
with + 0.75 DS/- 1.75 DC @ 110. The capsular bag is quite
stable with well-centered IOL. Combination of Cionnis ring
Department of Ophthalmology, Vasan Eye Care Hospital, Puducherry,
India
Correspondence to: Dr. Asim Kumar Kandar, Department of
Ophthalmology, Cataract, Cornea and Refractive Surgery Services, Vasan
Eye Care Hospital, No. 1, Villupuram Main Road, Puducherry - 605
005, India. E-mail: asimkk.aiims@gmail.com
Manuscript received: 21.07.13; Revision accepted: 17.02.14
Access this article online
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Website:
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DOI:
10.4103/0301-4738.138294

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