Retrobulbar Abscess in a Neonate

 

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Sir,

Orbital tumours in newborns are rare. In most cases they are either solid embryogenic tumours such as dermoid cysts [[3]] or vascular malformations such as capillary haemangiomas [[2]]. Common clinical characteristics are exophthalmia, conjunctival injections, periorbital redness, and amblyopia. This clinical picture is also present in patients with retrobulbar abscesses. Since a congenital retrobulbar abscess seems to be a very rare condition a report of a further case may be of interest.

A 10-day-old female was referred to our hospital because of redness and swelling of her right eye since birth. After an uneventful pregnancy she was born at 41 weeks of gestation. With the exception of the eye symptoms, her neonatal period was normal. Despite local administration of antibiotics assuming a conjunctival infection the eye symptoms worsened within the next days.

At 10 days of age her right eye showed prominent protrusion of the bulb, periorbital swelling and hyperaemia, conjunctival injections due to a permanent lagophthalmia and a purulent fluid along the lid (Fig. [1]). Internal and neurological examinations were normal, there was no history of fever. The laboratory parameters showed an erythrocyte sedimentation rate of 40 mm/h, a C-reactive protein of 1.3 mg/dl and a leukocytosis of 20,000 cells/µl. Since the girl's overall clinical picture resembled an infectious disease such as orbital phlegmone, we changed her medication to intravenous administration of ampicilline (100 mg/kg/d), oxacilline (100 mg/kg/d) and gentamycine (2 mg/kg/d). All vaginal cultures of the mother were sterile. Ophthalmologic examination did not reveal any abnormalities of the nasolacrimal ducts. MR imaging and CT scan of the orbits showed a large intraconal lesion (diameter 2 cm) located behind the globe and underneath the right optic nerve. The lesion presented as a homogenous structure, with sharp demarcation lines, poor contrast enhancement and a cyst within the central portion (Fig. [2] a).

Fig. 1 A 10-day-old neonate with exophthalmus and periorbital redness.

Fig. 2 Orbital MRI. a Preoperative T₁-weighted image after Gd-DTPA. Retrobulbar hypointensive lesion with marked peripheral enhancement. b Postoperative T₁-weighted image after Gd-DTPA. Mild exophthalmus with normal signal intensity of the retrobulbar tissue.

The lesion was biopsied using a transconjunctival approach. After a small incision along the inferior corner of the cornea, the conjunctiva was retracted and a solid encapsulated tumour was seen on the retrobulbar side of the muscle cone. Resection of the rostral capsule revealed a large amount of pus that was aspirated. Histological and microbiological examinations of the biopsy material established the final diagnosis of a retrobulbar abscess caused by Staphylococcus aureus and Streptococcus B. The patient was treated by local and intravenous application of antibiotics for a total of 18 days, followed by orally taking flucloxacilline for another seven days. Two months after treatment the girl showed only minimal exophthalmia of the right eye. MR imaging of the right orbit did not reveal any residual infiltrations (Fig. [2] b).

In summary, we describe a neonate with the uncommon and very rarely described finding of a congenital retrobulbar abscess. Known underlying causes of orbital tumours in children are infectious processes such as orbital phlegmone or abscess, vascular malformations such as capillary haemangioma or malignancies such as leukaemia, rhabdomyosarcomas and retinoblastomas, or solid tumours such as dermoid cysts [[2], [3], [4], [5]]. A congenital retrobulbar abscess of unknown origin caused the orbital tumour of the right eye in our patient. At birth, there was already a difference in terms of colour, size and opening of the lid between the patient's right and left eye indicating that the infection was already acquired intrauterine. The obstruction of the nasolacrimal ducts leading to dacryocystitis and rarely fistulation either externally to the skin or internally to the orbit as a possible cause could be excluded. The cause of the intrauterine infection in this patient could not be found. There have not been further microbiological investigations of placenta or amnion fluid.

Our case underlines the importance of biopsies in addition to laboratory and radiological investigations before treatment of orbital tumours in children.

The formation of congenital abscesses is a very rare intrauterine complication. Congenital abscesses located in the liver or the ilio-psoas have been reported in three cases after sepsis or infected amnion [[1]]. Retrobulbar abscesses have been reported in three cases due to dacryocystitis or ethmoiditis leading to fistulation [[4], [5], [6]]. Our case confirms and extends this group of congenital retrobulbar abscesses in neonates.

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Dr. med. A. Klusmann

Zentrum für Kinderheilkunde Heinrich Heine-Universität Düsseldorf

Moorenstraße 5

40225 Düsseldorf

Germany

Email: anne.klusmann@uni-duesseldorf.de