Strabismus, 15:215–219, 2007
Copyright

c 2007 Informa Healthcare USA, Inc.
ISSN: 0927-3972 print / 1744-5132 online
DOI: 10.1080/09273970701632007
Orbital Cellulitis after Faden Operation
on the Medial Rectus
Alejandro Armesto, MD
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Ophthalmology Department,
Hospital Alemán, Buenos Aires,
Argentina; Ophthalmology
Department, Hospital de
Clı́nicas, Buenos Aires
University, Buenos Aires,
Argentina
Marı́a Cristina Ugrin, MD
Ophthalmology Department,
For personal use only.
Hospital de Clı́nicas, Buenos
Aires University, Buenos Aires,
Argentina
Received 28 November 2006;
Accepted 20 June 2007.
Correspondence: Dr. Alejandro
Armesto, Dept. Ophthalmology,
Hospital Alemán, Av. Pueyrredón 1640,
1118 Buenos Aires, Argentina. Tel.:
+54 4827-7000; Fax: +54 4805-6087.
E-mail: larmesto@intramed.net
CASE REPORT
Background Orbital cellulitis after strabismus surgery is uncommon, may cause
blindness and may lead to death. Very few cases have been described in detail
due to the low incidence of this complication. Methods We report the first case
of orbital cellulitis following Faden operation on the medial rectus muscle. We
believe that the infection was due to asymptomatic ethmoid sinusitis. Our case
is compared with other cases previously reported. Results A two-year-old boy was
surgically treated for residual esotropia after two botulinum toxin A injections.
Two days after surgery, signs of orbital cellulitis developed in his right orbit. CT-
scan disclosed right ethmoid sinusitis that spread to the orbit after surgery. After
intravenous antibiotic treatment, the infection resolved with full restoration
of visual acuity and ocular motility. Conclusion Despite adequate measures to
prevent infection, orbital cellulitis may complicate strabismus surgery. Patients
must be instructed to recognize early symptoms of this severe infection and
call the surgeon immediately. Diagnosis may be confirmed by CT-scanning of
the orbits. Prompt treatment with intravenous antibiotics usually leads to full
recovery.
KEYWORDS Orbital cellulitis; strabismus surgery; ethmoid sinusitis; Faden operation;
intravenous antibiotics
INTRODUCTION
Orbital cellulitis is an unusual complication after strabismus surgery that
may lead to blindness or even death. Very few cases have been reported in detail
and, when Von Noorden published two cases in 1972, only four reports were
available in the literature, the last one dating from 1935 (Von Noorden, 1972).
We report the first case of orbital cellulitis following Faden operation on the
right medial rectus muscle. The infection was associated with an asymptomatic
right ethmoid sinusitis.
CASE REPORT
A two-year-old boy presented with residual esotropia after two botulinum
toxin type A injections in both medial rectus muscles for congenital esotropia
(Ciancia syndrome). Examination revealed 40 prism diopters (PD) of esotropia at
215
 FIGURE 1 The patient on the third postoperative day with signs
of orbital inflammation.
distance with bilateral limitation of abduction and al-
ternate fixation. He had +3 D hyperopia OU and the
angle of deviation did not improve with the use of
glasses. Surgery was scheduled after a follow-up period
of 7 months. His preoperative tests and clinical evalua-
tion were normal.
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Before starting the surgery an antiseptic solution of
povidone-iodine 5% was administered to the surface of
both eyes and culs-de-sac, and a povidone-iodine 10%
solution was applied to the skin of his face. Surgery was
carried out under general anesthesia and consisted of a
3.5 mm bilateral medial rectus recession combined with
posterior fixation sutures of non-absorbable polyester
fiber (Mersilene) placed 12 mm distant from the muscle
insertion (Faden operation). The right eye was operated
For personal use only.
first and the same surgical instruments and antiseptic so-
lution were used for both eyes. Surgery was uneventful.
FIGURE 2 CT-scan of both orbits: abnormal density is observ-
able in right ethmoid sinuses, suggesting sinusitis (white arrow);
right internal rectus is enlarged (black arrow) and surrounding
orbital tissues also show signs of inflammation.
A. Armesto & M.C. Ugrin
FIGURE 3 The patient one month after resolution of orbital cel-
lulites.
On the first postoperative day the child was or-
thophoric and his ocular examination revealed typi-
cal postoperative mild hyperemia and inflammation of
both nasal quadrants. He was put on a regimen of top-
ical tobramycin and dexamethasone 4 times a day and
was asked to return in one week.
During the second postoperative day, the right eye-
lid swelling increased and there was purulent discharge
from the right eye, but visual acuity and ocular motil-
ity were normal. Preseptal cellulitis was diagnosed and
oral cephalexin was added to the topical treatment. On
the third postoperative day, eyelid inflammation wors-
ened, leading to inability to open the eye voluntarily;
the conjunctiva was severely chemotic and there was
limitation of adduction of the right eye (Fig. 1). The
child was febrile and visual acuity was impossible to as-
sess. Computed tomography of the orbits disclosed in-
flammation of the right ethmoid sinuses, right medial
rectus enlargement and slight proptosis with swelling
of orbital tissues on the same side (Fig. 2). The diag-
nosis of orbital cellulitis secondary to ethmoid sinusitis
was made and the child was hospitalized. Conjunctival
cultures were taken and a regimen of intravenous ceftri-
axone and dexamethasone was instituted. The pathogen
was not identified but after ten days of treatment the in-
fection resolved, ocular motility was fully restored and
the child was discharged. One month later he was or-
thophoric (Fig. 3) with normal ductions and his visual
acuity was 20/80 OU (with the Lea Test).
DISCUSSION
The classification of cellulitis in the orbital region
proposed by Chandler includes five groups: presep-
tal cellulitis, orbital cellulitis, subperiosteal abscess, or-
bital abscess and cavernous sinus thrombosis (Rootman
et al., 1995). Orbital cellulitis is an infection of the
orbital tissues posterior to the orbital septum and its
most frequent signs are eyelid swelling, disturbance
of eye movements, exophthalmos, diminished visual
216
 acuity, afferent pupillary defect, pain on eye move-
ments, and fever. Before the development of antibi-
otics, 17% of patients with orbital cellulitis of any cause
died from meningitis and 20% of the survivors ended
blind (Wilson & Paul, 1987); nowadays, it is still a life-
threatening and vision-threatening condition, particu-
larly in children.
Orbital cellulitis after ophthalmic surgery is uncom-
mon. It has been reported in very small numbers after a
great diversity of surgical procedures such as blepharo-
plasty, cataract surgery, peribulbar anesthesia, aque-
ous drainage devices, radial keratotomy and strabismus
surgery (Casu & Pitzorno, 1988; Hofbauer et al., 1994;
Hoyama et al., 2006; Marcet et al., 2005; McLeod et al.,
1995; Palamar et al., 2005; Sharma et al., 2005; Von
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Noorden, 1972; Weakley, 1991; Wilson & Paul, 1987).
Von Noorden (1985) suggested that endophthalmitis
following strabismus surgery could be more frequent
than orbital cellulitis, but Ing (1991) surveyed 63 stra-
bismus surgeons regarding the incidence of infection
following strabismus surgery and found that orbital cel-
lulitis occurred in 1 per 1900 cases and endophthalmitis
in 1 per 30,000 cases.
Few cases of orbital cellulitis following strabismus
For personal use only.
surgery have been described in detail and most of those
reports date from the second half of the 20th century.
Four cases were published in the preantibiotic era, be-
tween 1880 and 1935, and it was not until 1972 that
another two cases were described by Von Noorden
(1972). Seven previous reports are compared with ours
in Table 1 (Casu & Pitzorno, 1988; Hoyama et al., 2006;
Palamar et al., 2005; Von Noorden, 1972; Weakley,
1991; Wilson & Paul, 1987).
In 1995, given the low incidence of orbital celluli-
tis after strabismus surgery (1/1100–1/1900 operations),
Kivlin, Wilson and the Periocular Study Group sur-
veyed 419 members of AAPOS (Kivlin et al., 1995).
Twenty-five of the submitted cases met the inclusion
criteria and were analyzed, but only 17 of them had
signs of deep orbital infection and/or had a CT-scan or
MRI that was positive for orbital cellulitis. Signs and
symptoms appeared within the first 5 days after surgery
in all cases. The most common pathogen detected in
conjunctival cultures in this series was Staphylococcus
aureus (56%), and 72% of patients had the expected
postoperative ocular alignment after resolution of the
cellulitis.
Most reports of orbital cellulitis following strabismus
surgery lack information about the antiseptic measures
217
taken prior to the surgery (see Table 1). No treatment to
completely sterilize the ocular surface exists, but anti-
sepsis for ocular surgery is crucial to avoid serious post-
operative complications. The effectiveness of povidone-
iodine 5% solution to reduce both the colony counts
and the incidence of endophthalmitis after intraocu-
lar surgery have been widely recognized, and that ef-
fect might be enhanced if neomycin drops were added.
Preoperative treatment with antibiotic drops is recom-
mended for selected cases, and there is no agreement
about what antibiotic is the best to use for this purpose,
nor what the adequate dosage is (Nesi et al., 1998). In
our patient, adequate antisepsis was carried out before
starting the surgery. His right eye was operated first and
the same surgical instruments and antiseptic solution
were used for both eyes.
In most cases, the source of the infection could not
be determined, but the most commonly reported cause
was deficient patient hygiene. Sinusitis is the cause of
orbital cellulitis in more than 50% of cases not associ-
ated with surgery, and is difficult to diagnose in children
without a CT-scan. Sinus infection may spread to the
orbit through the thin and discontinuous bony walls,
or by means of the orbital and sinus venous systems,
which lack valves (Rootman et al., 1995). In our case,
CT-scan disclosed right orbital cellulitis and ipsilateral
ethmoid sinusitis. We ruled out the possibility that in-
fection was acquired during surgery because we used
the same surgical instruments and sutures for both eyes
and the right eye was operated first. Although conjunc-
tival cultures were negative and nasal cultures were not
taken, we believe that the source of infection was the
contiguous ethmoid sinusitis.
Surgery consisted of a bimedial rectus recession com-
bined with posterior fixation sutures (Faden operation).
This procedure requires both the disinsertion of the me-
dial rectus pulley in order to let the muscle displace
backward and the placement of two Mersilene stitches
18 mm distant from the limbus. Given that this surgical
technique involves orbital tissues close to the ethmoid
cells and that the orbital septum may have been in-
advertently opened, we hypothesize that inflammation
consecutive to the surgery could have facilitated the
hematogenous spread of infection. Nevertheless, coin-
cidence cannot be ruled out since there are reports of
patients that developed an orbital cellulitis associated
with sinusitis after strabismus surgery was cancelled.
CT-scan also revealed right eye proptosis and enlarge-
ment of the right medial rectus, which was also slightly
Orbital Cellulites after Faden Operation
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TABLE 1 Comparison of the present case with seven cases from the literature.
von Noorden von Noorden Wilson Casu Weakley Palamar Hoyama Present
Case #1 (1972) #2 (1972) (1987) (1988) (1991) (2005) (2006) case

Age 2 yrs. 1 yr. 4.5 yrs. 12 yrs. 65 yrs. 16 yrs. 56 yrs. 2 yrs.
Operated muscle of LMR LLR LMR LLR RLR LLR LIR LMR LLR LMR RMR
the infected eye
Beginning 48 hs 72 hs 48 hs 24 hs 48 hs 72 hs 24 hs 48 hs
of symptoms
Preop Not stated (NS) NS NS NS NS NS NS No
antibiotics
Intraop NS NS NS NS NS NS NS Yes (intravenous
antibiotics cephalexin)
Postop NS NS no Yes (topical) Yes (topical) Yes (topical) NS Yes (topical)
antibiotics
Preop antisepsis NS NS Yes NS NS Yes NS Yes
First postop 24 hs 24 hs Not clear 24 hs 24 hs 24 hs 24 hs 24 hs
visit (24–72 hs)
CT/MRI Was not Was not CT CT CT CT CT CT
available available
Conjunctival culture +(St. aureus) – +(Strep. A beta.) Not performed +(St. aureus) – – –
Blood culture – – NS Not performed – NS NS Not performed
Presumed source Unknown Unknown Deficient patient Deficient patient NS Unknown Unknown Ethmoid sinusitis
of infection (postoperative) (postop) hygiene (postop) hygiene (postop) (postop) (preop)
Treatment i.v. ATB + i.v. ATB + i.v. ATB i.v. ATB + i.v. ATB + topical i.v. ATB + i.v. ATB + topical i.v. ATB +
topical ATB topical ATB topical ATB ATB + canthotomy topical ATB ATB + canthotomy topical ATB
Time for recovery 15 days 15 days 11 days 5 days 7 days 14 days 4 months 10 days
Final visual acuity NS NS NS NS 20/30 + 20/40 No light 20/80
slipped muscle (same as preop) perception (normal)

218
 paretic due to the inflammatory condition. All signs and
symptoms resolved after intravenous antibiotic therapy,
with full restoration of ocular motility and orthophoric
alignment.
Strabismus surgery patients are frequently asked to
return on the first postoperative day and a week after
surgery, but orbital cellulitis can develop within two
to five days after the operation. In view of the pos-
sibly rapid onset of infection, it would be reasonable
to instruct the patients in recognizing the signs and
symptoms of infection so that they can call the surgeon
immediately.
When orbital cellulitis is suspected, computerized to-
mography of the orbits, conjunctival culture and blood
cultures are mandatory to define the diagnosis, followed
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by immediate assertive treatment.
ACKNOWLEDGMENTS
The authors thank Anthony Arnold, MD and Laura
Bonelli, MD.
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Orbital Cellulites after Faden Operation