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Clinicopathologic Reports, Case Reports, and Small Case Series
June 2002

Orbital Cellulitis as a Late Complication of Glaucoma Shunt Implantation

Arch Ophthalmol. 2002;120(6):849-851. doi:

Orbital cellulitis is a rare complication of glaucoma tube shunt implantation. We describe a patient who developed orbital cellulitis 15 months after placement of a Baerveldt tube shunt (Pharmacia Corporation, Peapack, NJ). The proximal portion of the Baerveldt tube shunt had eroded through the conjunctiva, presumably serving as a portal of entry for microorganisms. The cellulitis was successfully treated with intravenous antibiotics and subsequent removal of the glaucoma tube shunt.

Report of a Case

A 78-year-old African American woman was seen with a 3-day history of left eye pain, eyelid swelling, and decreased vision in her left eye. According to the referring ophthalmologist, the left intraocular pressure had become elevated to the 40–mm Hg range and vision had worsened from counting fingers to no light perception over the preceding 3 days. She had been treated with oral acetazolamide, timolol maleate, dorzolamide hydrochloride, and brimonidine tartrate.

The patient had an extensive medical and ocular history. She had hypertension, gout, and hypothyroidism and had undergone aortic valve replacement and bilateral knee replacements. In the right eye, she had undergone multiple penetrating keratoplasties for Fuchs endothelial dystrophy and graft failure. She also had placement of a Baerveldt tube shunt (350 mm2) for chronic angle-closure glaucoma. In the left eye, she had undergone penetrating keratoplasty with cataract extraction and intraocular lens implantation. Three years later, she underwent implantation of a Baerveldt tube shunt (350 mm2) for chronic angle-closure glaucoma. Four months following insertion of the glaucoma tube shunt, she underwent repeated penetrating keratoplasty, anterior synechialysis, and shunt revision for iris incarceration of the tube. subsequently, she required surgical drainage of peripheral choroidal effusions and scleral patch graft reinforcement for tube erosion through the conjunctiva 11 months prior to initial examination.

She was afebrile at clinical examination. Visual acuity was light perception in the right eye and hand motions temporally in the left eye (her visual acuity was 20/400 OS 1 year previously). The intraocular pressures were 19 mm Hg OD and 12 mm Hg OS. She had a right relative afferent pupillary defect with 50% light desaturation. Ocular ductions were full in the right eye. In the left eye she had severe limitation of motility in all directions. There was swelling, erythema, tenderness, and warmth of the left upper eyelid, and the globe was inferiorly displaced. The left conjunctiva also had diffuse hyperemia and was chemotic. On computed tomography of the orbits, preseptal soft tissue swelling was extended from the region of the glaucoma tube shunt, with some infiltration of the intraconal fat (Figure 1 and Figure 2). Biomicroscopic and fundus examination findings did not reveal any evidence of endophthalmitis or panophthalmitis.

Figure 1
 Computed tomographic scan of the
orbits with contrast (axial section) demonstrates preseptal soft tissue swelling
surrounding and extending from the region of the left Baerveldt tube shunt
(long arrow). Infiltration of the orbital fat is also apparent (short arrow).
Of note is that Baerveldt tube shunts are impregnated with barium and therefore
are radio-opaque.

Computed tomographic scan of the orbits with contrast (axial section) demonstrates preseptal soft tissue swelling surrounding and extending from the region of the left Baerveldt tube shunt (long arrow). Infiltration of the orbital fat is also apparent (short arrow). Of note is that Baerveldt tube shunts are impregnated with barium and therefore are radio-opaque.

Figure 2
 Computed tomographic scan of the
orbits with contrast (coronal section) demonstrates inferior displacement
of the globe, as well as inflammation around the levator–superior rectus
complex (arrow).

Computed tomographic scan of the orbits with contrast (coronal section) demonstrates inferior displacement of the globe, as well as inflammation around the levator–superior rectus complex (arrow).

The patient was admitted and started receiving intravenous ampicillin sodium/sulbactam sodium. The ocular motility and eyelid swelling improved dramatically within 24 hours. Intravenous methylprednisolone sodium succinate (Solu-Medrol; Pharmacia Corporation) was then added. Following several more days of intravenous antibiotics, the left conjunctival hyperemia became localized to the superotemporal quadrant region. There was conjunctival erosion and exposure of the proximal portion of the Baerveldt tube with negative Seidel test results (Figure 3). The bleb over the tube shunt appeared convex (indicative of a functional shunt implant).

Figure 3
 Anterior segment biomicroscopy
reveals erosion of the Baerveldt tube through the conjunctiva (arrow).

Anterior segment biomicroscopy reveals erosion of the Baerveldt tube through the conjunctiva (arrow).

Given the persistent ocular pain and redness, the glaucoma tube shunt was surgically removed. No growth was observed from any of the bacterial cultures. The patient's ocular symptoms resolved and her visual acuity improved to counting fingers range. Moreover, the left intraocular pressure remained stable with antiglaucoma medication.

Comment

Orbital cellulitis is a rare complication of glaucoma tube shunt implantation. To our knowledge, this is the first case of orbital cellulitis reported in a patient with a functioning tube shunt. A case of orbital cellulitis was reported in a child 1 month following a stage 1 Molteno shunt procedure.1 The tube had been tucked under the conjunctiva and was found to have slipped out, presumably creating a portal of entry for infection. The patient was treated with systemic antibiotics and required removal of the shunt. In contrast, our case involved a functional glaucoma tube shunt of over 1 year's duration that eroded through the conjunctiva. The differential diagnosis also included an orbital inflammatory syndrome. Indeed, myositis has been reported to be associated with Baerveldt tube shunt surgery.2 This case occurred in a patient with a history of ocular myositis before glaucoma tube shunt surgery. However, our patient's rapidly progressive course, her dramatic improvement with intravenous antibiotics, and the computed tomographic scan findings in the left orbit are consistent with an infectious process.

Orbital cellulitis has occurred in patients with other periocular implants, including scleral buckles.3 Infections with scleral buckles have usually been associated with exposure of the implant or explant. The treatment of these infections almost invariably requires removal of the element, as well as treatment with antibiotics.4

We believe that exposure of the Baerveldt tube through the conjunctiva allowed entry of microorganisms into the subconjunctival space and secondarily into the orbit. Given the lengthy duration between the scleral reinforcement surgery and the development of cellulitis, it is unlikely that residual buried epithelium from the reinforcement surgery could have caused the delayed glaucoma tube shunt exposure. Exposure of glaucoma tube shunts may be managed successfully with anterior surgical revision5 and/or pars plana vitrectomy and repositioning the tube into the vitreous cavity.6 However, in the setting of active orbital cellulitis, immediate treatment with intravenous antibiotics is necessary. subsequent removal of the glaucoma tube shunt implant may be required for complete resolution of the infection.

This work was supported in part by the Homer McK Rees Scholar Award (Dr Tsai) and an unrestricted grant from Research to Prevent Blindness Inc, New York, NY.

The authors have no proprietary interest in any of the products mentioned.

Corresponding author and reprints: James C. Tsai, MD, Harkness Eye Institute, 635 W 165th St, New York, NY 10032 (e-mail: jct2002@columbia.edu).

References
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Karr  DJWeinberger  EMills  RP An unusual case of cellulitis associated with a Molteno implant in a 1-year-old child. J Pediatr Ophthalmol Strabismus. 1990;27107- 110
2.
Kean  OTAlward  WLMKardon  RH Myositis associated with a Baerveldt glaucoma implant. Am J Ophthalmol. 1999;128375- 376Article
3.
Kanski  JJGregor  Z Retinal Detachment: A Colour Manual of Diagnosis and Treatment. 2nd Oxford, England Butterworth-Heinman Ltd1994;128- 129
4.
Smiddy  WEMiller  DFlynn  HW Scleral buckle removal following retinal reattachment surgery: clinical and microbiologic aspects. Ophthalmic Surg. 1993;24440- 445
5.
Tsai  JCGrajewski  ALParrish  RK  II Surgical revision of glaucoma shunt implants. Ophthalmic Surg Lasers. 1999;3041- 46
6.
Joos  KLaviña  AMAgarwal  ATawansy  K Successful repositioning of glaucoma shunt implants after pars plana vitrectomy for anterior segment complications. Ophthalmology. 2001;108279- 284Article
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