centrally within muscle cone); presents with signs of orbital involvement with proptosis, impaired extraocular movements, visual loss; Rx: urgent surgical decompression with parenteral antibiotics
• Class V (Cavernous Sinus Thrombosis/Thrombophlebitis): mural thrombus formation in ophthalmic veins due to compression and stasis, travels posteriorly towards cavernous sinus with potential to embolize; commonly involves Staphylococcus aureus or Streptococcus species
1. Invariably presents with signs of orbital involvement (rapidly progressive chemosis, proptosis, ophthalmoplegia, decreased visual acuity)
2. “Picket fence” spiking fevers, other cranial nerve palsies (CN II, III, IV, V1; and V2, VI), photophobia, hypopituitarism, sepsis, and intracranial complications (meningitis, septic emboli)
3. CT or MRI may show intraluminal enhancement, CT or MR venogram may show filling defect, Tobey-Ayer/Queckenstedt test (external compression of neck veins does not cause an increase in CSF pressure on obstructed side), lumbar puncture for CSF studies if no risk of brain herniation from increased ICP or mass effect, blood cultures
Superior Orbital Fissure Syndrome
• Fixed or frozen globe (CN III, IV, VI), dilated pupil (CN III), ptosis (CN III), hypesthesia of upper eyelid (CN V1)
Orbital Apex Syndrome
• Similar to superior orbital fissure syndrome with added involvement of CN II (papilledema, vision changes)
• Must rule out tumor, local edema, allergy, blunt trauma, and acute invasive fungal sinusitis (especially in immunocompromised patients)
• Though uncommon, severe chronic rhinosinusitis or fungal sinusitis may cause compression of CN II within the sphenoid and lead to vision loss, mimicking orbital complications.
• Ophthalmology consultation is indicated to assess vision, visual fields, pupillary reactivity, extraocular movements, and intraocular pressure; loss of red/green perception occurs prior to deterioration of visual acuity.
• Endoscopy-directed sinus cultures may be helpful in guiding antibiotic selection.
• CT of paranasal sinuses/orbits with and without IV contrast is the optimal imaging study to accurately stage orbital complications; as infection spreads from the ethmoid sinus to the orbit, the orbital periosteum will show enhancement along the lamina with eventual thickening and accumulation of low-density material as well as rim enhancement (abscess formation).
• Early and appropriate IV antibiotics will resolve the vast majority of cases.
• Empiric parenteral antibiotics should cover common suspected pathogens and penetrate the blood-brain barrier (ie, ceftriaxone/third-generation cephalosporin, ampicillin/sulbactam); antibiotics should be adjusted according to culture results (ie, aminoglycosides for gram-negative infections, vancomycin for resistant Staphylococcus aureus and Streptococcus pneumoniae).
• Aggressive nasal toilet including nasal irrigations and decongestants (use for no longer than 3 days to minimize risk of rhinitis medicamentosa).
• Corticosteroids are not typically recommended for orbital infection.
• For specific management according to Chandler classification, please see previous section.
• Indications for urgent surgical intervention
1. Orbital abscess
2. Large subperiosteal abscess (>1 cm)
3. Vision changes (acuity <20/60)
4. Complete ophthalmoplegia
5. Progression of ocular findings for >24 hours
6. No improvement or resolution after 48 to 72 hours of medical therapy
7. Involvement of opposite eye (may suggest worsening of sinonasal infection or cavernous sinus involvement)
8. Superior orbital fissure or orbital apex syndrome requires urgent surgical decompression
• Surgical intervention entails draining the subperiosteal/orbital abscess, addressing the involved sinuses, and obtaining intraoperative cultures; approaches can be endoscopic, open, or combined, depending on the location and extent of the fluid collection.
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