Demographics
The adult patients, 16 males and 10 females that were diagnosed with OC, had a median age of 48 years (range 32.75-66.50). All patients presented with OC in only one eye, with 14 cases that occurred in the right eye and 12 cases that occurred in the left eye. The patients were divided into three groups according to etiology: (1) patients secondary to rhinosinusitis, (2) patients secondary to endogenous infection(s) without endophthalmitis, and (3) patients secondary to endophthalmitis. In the six cases comprising group 1, the instances of OC were split evenly between the right and left eyes. Group 2 (n=3) included two right eye cases and one left eye case. Finally, in group 3 (n=17), nine and eight cases presented in the right and left eyes, respectively (Tables 1, 2, 3). There were no significant differences in age or gender among the three groups (P>0.05).
Clinical Presentation
Group 1 and group 2 patients presented with blepharedema and moderately reduced visual acuity. Group 1 had five cases with exophthalmia and five cases with ophthalmoplegia, while group 2 had two cases with exophthalmia and two cases with ophthalmoplegia, with one patient presenting with both (Tables 1, 2). The patients in group 3 presented with blepharedema and severe visual impairment: 11 cases with exophthalmia, 5 cases with ophthalmoplegia. The best-corrected visual acuity (BCVA) of 15 cases presented with no light perception (NLP), 1 case had LP, and 1 case had BCVA of 2/20 (Tables 3).
Combined Systemic Diseases
OC does not always present alone. Two cases were complicated with diabetes in group 1, and 1 case was secondary to T-cell lymphoma. In group 2, two cases were complicated with iron-deficiency anemia or secondary to acute lymphocytic leukemia. Five cases were caused by trauma in group 3. Furthermore, 3 cases were complicated with liver or cervical abscesses, and 10 cases were complicated with other systemic diseases including sepsis, diabetes, hypertension, organ failure, or hematopathy (Tables 1, 2, 3).
Leukocyte Counts
Routine blood examinations were performed on all patients, and leukocyte counts were analyzed. The normal value of leukocyte counts was 4.0-10.0×1000/uL. The leukocyte counts of 6 patients, 3 patients, and 16 patients were abnormal before the treatment in groups 1, 2, and 3, respectively. While after treatment, the leukocyte counts of 5 patients and 16 patients returned to normal in groups 1 and 3, respectively. However, the total leukocyte counts of 3 patients in group 2 remained abnormal consistently. (Table 1, 2, 3).
Blood Cultures
Blood cultures were obtained from all patients, the bacterial culture and fungal culture were both ordered in the blood culture, and three of them were positive. Two cases tested positive with Klebsiella pneumoniae, and one case showed positive with Pseudomonas aeruginosa. The fungal cultures were all negative. (Table 2, 3).
CT or MRI
Each patient received CT initially. MRI was performed in ten patients. (Table 1, 2, 3). CT scans revealed swollen orbital soft tissue, increased fat density, and opacification of the involved sinuses in the patients with sinusitis. Two cases presented bony destruction, and thickening of the associated muscles was present in eight cases. Optic nerve involvement was demonstrated in one case. In addition, we observed one case combined with cavernous sinus thrombophlebitis.
MRI revealed ill-defined infiltration of orbital fat. Only four cases demonstrated an extremely hyperintense signal representing orbital abscess formation when analyzed by diffusion-weighted imaging (DWI) and the corresponding hypointense signal on the apparent diffusion coefficient (ADC).
Length of Stay
In group 1, the mean hospital stay was 17.17±9.87 days, and the mean time to discharge after operation was 12.33±9.45 days. For group 2, the mean hospital stay was 19.33±3.06 days, and the mean time to discharge after operation was 2.00 ±3.46 days. Finally, in group 3, the mean hospital stay was 11.94±5.73 days with a mean time to discharge after operation of 5.71±3.80 days (Table 1, 2, 3).
Therapeutic Methods and Prognosis
All patients diagnosed with OC were treated with active treatments once admitted to the hospital, including systemic, topical antibiotics, and further therapeutic plans were made according to the patients' conditions.
Three cases in group 1 were treated with endoscopic sinus surgery, while another three cases were treated conservatively. Only one patient could not visualize hand motion at the time of hospitalization and had NLP at the time of discharge. In this case, we considered that inflammation spread to the optic nerve. One case in group 2 was treated with abscess incision, and the other two cases were treated with conservative treatment.
Six cases in group 3 were treated with intravitreal injection of vancomycin and cefazolin. Five and two cases were treated with the evisceration of eye contents and enucleation, respectively. Abscess incision treated two cases, and three cases were treated with conservative treatment. Unfortunately, all patients had a BCVA of NLP (Table 1, 2, 3).
Microbial cultures of the drained abscesses from three patients were performed, and Klebsiella pneumoniae was identified and cultured in one patient. In two patients, there was no growth reported.
Group Comparisons
There were no significant differences in preoperative leukocyte count, exophthalmia, blood culture, treatment, and visual changes among the three groups (P>0.05). There were significant differences in postoperative leukocyte count and ophthalmoplegia between the three groups (P<0.05). The preoperative and postoperative minimum resolution angle in logarithm best-corrected visual acuity (LogMAR BCVA) of group 3 were statistically significant compared with group 1 and group 2 (P<0.05) (Table 4, 5).