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A 39-year-old man with painful proptosis after dental extraction
Digital Journal of Ophthalmology 2008
Volume 14, Number 4
February 7, 2008
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Brett Kotlus | Allure Medical Spa
Veena Kumar | Maxwell Aesthetic Surgery
Robert Cravens | Tucson Ear Nose and Throat
Robert Dryden | Arizona Centre Plastic Surgery
Diagnosis and Discussion
The most common organisms causing acute orbital and sinus infections in adults include Streptococcus, Haemophilus, and Moraxella species. Immunocompromised individuals may harbor unusual organisms.(1) Cases of orbital infections caused by gas-forming bacteria are uncommon and have rarely been well documented.(2,3) We describe a case of an orbital abscess caused by gas-forming bacteria.

Intraorbital gas due to an infectious agent is an uncommon finding(2,3) and indicates the need for prompt surgical intervention and/or treatment with broad-spectrum antimicrobial agents. Anaerobic organisms must be considered when choosing an antibiotic in these cases. The patient presented here had undergone a dental extraction, which has been associated with transient bacteremia, including anaerobic species.(4) The possibility of hematogenous spread cannot be ruled out as the orbital collection in this case was posterolateral to the globe and direct intraorbital extension of an infectious sinus process is more frequently medially located. In patients with this clinical picture, further investigation for other sites of bacteremic seeding may be warranted.

Atypical organisms are potential offending infectious agents in immunocompromised individuals.(1) There should also be high suspicion for fungal infections in this patient population. This patient had been treated with oral steroids without antibiotics for 5 days prior to presentation and this may have contributed to the development of gas-producing bacteria.

The formation of gas has most commonly been linked to Clostridium perferingens, but other bacteria including Staphylococci, Streptococci, and other anaerobes have been shown to be capable of causing gas-forming infections.(5) Initial antibiotic treatment should be guided by the results of Gram stain and deliberation of possible etiologic agents based on clinical findings. The excellent outcome in the patient presented here can be attributed in part to prompt and aggressive treatment.