A 41-yr old male patient had visited our hospital due to symptoms of severe right facial and periorbital edema, proptosis, ocular pain, decreased visual acuity, diplopia and nasal stuffiness on June 11, 2011. The patient had dental root of the right upper premolar tooth broken accidentally 2 months ago. He endured the condition untreated until the pain became very severe. He visited a private dental clinic and was diagnosed with a periodontal abscess of the right upper premolar tooth 4 days before visiting our hospital. There he was treated with antibiotics, but swelling of the right mandible and cheek area began on the first following day. In addition, periorbital swelling, proptosis and nasal bleeding began on the second following day. The facial and periorbital swelling became more aggravated and the patient was referred to our hospital (). The patient had no specific past medical history. From the ophthalmologic examination, his best corrected visual acuity was 20/100 for the right eye and 20/20 for the left eye. The intraocular pressure was 54 mmHg in the right eye and 12 mmHg in the left eye. In the examination of eyeball movement, his right eye had shown severe limitation of movement in all directions (). Exophthalmometry was measured to be 20 mm in the right eye and 14 mm in the left eye. The right eyelid was very tight and tender at palpation. Severe conjunctival injection and chemosis were also observed. Because the right eyelid could not be closed completely due to proptosis, conjunctival prolapse was observed through the lid fissure. On the slit lamp examination, epithelial erosion and mild stromal edema of the cornea were observed. The anterior chamber of the right eye showed a center depth of 2.5 CT (corneal thickness) which was rather shallower than 4 CT in the left eye. But there was no floating inflammatory cell in the anterior chamber. At the time of the initial examination, pupillary response was normal and no abnormal finding was observed from fundus examination. The color vision test was also normal. In facial CT, findings of severe sinusitis in the right maxillary sinus and inflammation of the right temporalis and mastication muscles were observed. Also, findings of severe inflammation in orbital soft tissue and extraocular muscles, which is correspond with the findings of orbital cellulitis, were observed (). Increase in leukocyte count, erythrocyte sedimentation rate, and C-reactive protein level were found in the blood sampling test. Upon diagnosis of orbital cellulitis spreading from odontogenic sinusitis, the patient was immediately hospitalized. Intravenous administration of ceftriaxone and clindamycin began with medications for lowering intraocular pressure. The intraocular pressure of the right eye had decreased to 34 mm Hg on the following day of hospitalization. However, the facial and periorbital swelling had not improved and further aggravated. Therefore, emergent maxillary sinus drainage was performed in the department of otolaryngology. On the day following surgery, the patient complained of a sudden deterioration of vision in the right eye. The measured visual acuity was only light perception and intraocular pressure was 42 mmHg with afferent pupillary defect in the right eye. Pale optic disc, cherry red spot in the fovea and retinal edema were found from the fundus examination (). In fluorescein angiography, delay of retinal circulation was observed (). Ischemic optic neuropathy and central retinal artery occlusion were diagnosed by these findings. Severe proptosis and deformation of the posterior pole of the right eye into a cone shape by severe stretching of the optic nerve were found in the orbital CT (). Immediate ocular massage, emergent anterior chamber paracentesis and lateral canthotomy were performed. However, those trials were useless. While maintaining ocular hypotensives and antibiotics, the intravenous administration of high-dose steroid (methylprednisolone, 1 mg/kg/day) started. After 5 days, the intravenous steroid was replaced with oral prednisolone at a dosage of 60 mg/day for 1 week and thereafter the dosage was gradually reduced. Meanwhile, Staphylococcus epidermidis was identified from a microbiologic culture at the time of sinus drainage. The patient began to show improvement of facial and periorbital edema after 5 days of hospitalization and the intraocular pressure had returned to normal range. After 12 days of hospitalization, proptosis, limitation of eyeball movement, and afferent pupillary defect had been resolved, but the visual loss had not recovered at all ().
Fig. 1 Photographs of the patient's face. (A) The face showed marked swelling of right cheek and periorbital area involving eyelid, severe proptosis of the right eye. (B) Nine cardinal gaze photographs showed severe limitation of the right eyeball movement for (more ...)
Fig. 2 CT findings of the patient. (A) Coronal CT scan at presentation showed severe maxillary and ethmoidal sinusitis as well as marked inflammatory swelling of soft tissue in the right cheek and temporal region. Intraorbital soft tissue inflammation and thickening (more ...)
Fundus findings of the patient. (A) Fundus photograph of the right eye showed a pale optic disc, cherry red spot in macula, and edema at the posterior pole. (B) Fluorescein angiography of right eye showed a delay of retinal circulation.
Swelling of the cheek and proptosis of the right eye had nearly subsided after 2 weeks of hospitalization but visual loss had not been recovered.