Massive Orbital Abscess After Orbital Wall Fracture

FIG. 1FIG. 2CASE PRESENTATION A 40-year-old male presented to an outside hospital with mild periorbital edema, 6 days after being punched in the face. Initial orbital CT showed a left medial and inferior orbital wall fracture, maxillary opacification, "hematoma" surrounding the inferior rectus, and poor dentition including a periapical abscess highlighted in Fig. 1A. He was discharged with sinus precautions. Two weeks later, he presented with significantly worsening periorbital edema and vertical diplopia; his external exam showed spontaneous cutaneous drainage of purulent material through the lower eyelid (Fig. 1B). He had a visual acuity of 20/40 in the OS, no dyschromatopsia or pupil abnormalities, and normal intraocular pressures. A limited dilated eye exam showed a normal optic nerve and posterior pole. A repeat CT showed incomplete maxillary opacification, fat stranding, and a large orbital abscess with impressive mass effect and superior displacement and compression of the globe along the superior orbital rim (Fig. 2). He was started on intravenous vancomycin, cefepime, and metronidazole, and taken for urgent anterior orbitotomy and endoscopic maxillary antrostomy. A large preseptal and orbital abscess was drained; intraoperative cultures grew Streptococcus mitis, commonly found in oral flora suggesting that sinusitis from an odontogenic origin seeded the orbit after trauma. At 2-week follow up, he had no diplopia and his vision had returned to baseline. Concurrent sinusitis and poor dentition at the time of orbital fractures should raise concern for orbital infections, especially in the setting of abnormal orbital imaging findings. Vision-threatening orbital abscesses can develop days to even weeks after the initial trauma.