Porous polyethylene implant associated with orbital cellulitis and intraorbital abscess

Abstract

Orbital cellulitis and intraorbital abscess following orbital wall fractures is a rare complication that is reported at a rate of 0.18%.1Ben Simon G.J. Bush S. Selva D. McNab A.A. Orbital cellulitis: A rare complication after orbital blowout fracture.Ophthalmology. 2005; 112: 2030-2034Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar, 2Warrier S. Prabhakaran V.C. Davis G. Selva D. Delayed complications of silicone implants used in orbital fracture repairs.Orbit. 2008; 27: 147-151Crossref PubMed Scopus (21) Google Scholar They typically occur within 2 to 5 weeks after the fracture1Ben Simon G.J. Bush S. Selva D. McNab A.A. Orbital cellulitis: A rare complication after orbital blowout fracture.Ophthalmology. 2005; 112: 2030-2034Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar and carry increased risk if there was a preceding sinus infection or history of nose blowing.1Ben Simon G.J. Bush S. Selva D. McNab A.A. Orbital cellulitis: A rare complication after orbital blowout fracture.Ophthalmology. 2005; 112: 2030-2034Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar A 30-year-old man from a corrections center presented with a 1-day history of a red, swollen right upper eyelid. Two months earlier, he had sustained an orbital floor fracture resulting from an assault by a fellow inmate. The repair was performed 24 hours after the assault, using a porous polyethylene implant presoaked in antibiotic (80 mg gentamycin in 5 mL saline). There was no history or CT scan evidence of sinusitis at the time of injury. On initial presentation to the plastics service, the patient had minimal erythema and edema of the right upper lid. Visual acuity was 20/20. The rest of the examination was normal. A presumptive diagnosis of preseptal cellulitis was made, and the patient was treated with oral cefaclor. An urgent CT scan showed opacification of the right maxillary sinus extending through the floor (Fig. 1), and a collection of air. There was no history of the patient's blowing his nose. The patient was started on IV ceftriaxone, and 18 hours later, he complained of decreased vision and ocular pain. Examination revealed increased chemosis and injection, proptosis, periorbital edema, and limitation in extraocular movements. Visual acuity had decreased to 20/30 (Fig. 2). Color vision was normal, and there was no evidence of an afferent defect. A repeat CT scan revealed right orbital cellulitis and intraorbital abscess communicating with an inferior extraorbital abscess. The patient underwent emergent removal of the porous polyethylene implant, through a transconjunctival approach. Intraoperative cultures revealed a multibacterial organism infection (gram-positive cocci and rods, gram-negative rods, and anaerobic organisms). One month postoperatively, the patient had a residual enophthalmos of 3 mm but vision had returned to 20/20. Various orbital implants have differing complication rates. Older implants such as calvarial bone and cartilage have complication rates of 26%, whereas polydioxane implants have complication rates of 5.4%.3Al-Sukhun J. Lindqvist A comparative study of 2 implants used to repair inferior orbital wall bony defects: Autogenous bone graft versus bioresorbable poly-L/DL-Lactide plate.J Oral Maxillofacial Surgery. 2006; 64 (C): 1038-1048Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar None have documented an orbital cellulitis or abscess.3Al-Sukhun J. Lindqvist A comparative study of 2 implants used to repair inferior orbital wall bony defects: Autogenous bone graft versus bioresorbable poly-L/DL-Lactide plate.J Oral Maxillofacial Surgery. 2006; 64 (C): 1038-1048Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar Supramid and Silastic implants have complication rates of 12% to 14% and have 1% to 2% complication rates of orbital cellulitis.4Cluster P.L. Lind A. Trinkaus K.M. Complications of supramid orbital implants.Ophthalm Plastic Reconstr Surg. 2003; 19: 62-67Crossref PubMed Scopus (45) Google Scholar A 10-year review comparing 405 cases of either hydroxyapatite or porous polyethylene implants reported a complication rate of 9.4% and 5.6%, respectively, of wound dehiscence and enophthalmos.5Nam S.B. Bae Y.C. Moon J.S. Kang Y.S. Analysis of the postoperative outcome of 405 cases of orbital fracture using 2 synthetic orbital implant.Ann Plast Surg. 2006; 56: 263-267Crossref PubMed Scopus (80) Google Scholar A study in 2006 reported an incidence of cellulitis of 0.5% for hydroxyapatite.5Nam S.B. Bae Y.C. Moon J.S. Kang Y.S. Analysis of the postoperative outcome of 405 cases of orbital fracture using 2 synthetic orbital implant.Ann Plast Surg. 2006; 56: 263-267Crossref PubMed Scopus (80) Google Scholar Our patient developed orbital cellulitis and intraorbital abscess 8 weeks after the repair of the floor fracture. There were no signs of sinus disease perioperatively, no history of nose blowing, and no surgical complications to account for the cause of an intraorbital abscess or orbital emphysema. This is the first reported case of porous polyethylene–related cellulitis with an intraorbital abscess requiring removal. The lack of risk factors and the late presentation illustrate the importance of close monitoring and follow-up to prevent sight-threatening complications.