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clinical improvement with serial measurements of visual acuity, pupillary evaluation, and motility and confrontation (or automated if available) visual field testing. In the absence of noticeable improvement within 24–48 h, CT scanning is repeated and antibiotic modification considered. Radiologic identification of an orbital abscess, particularly in an adult, usually mandates surgical intervention.
11.2.3.2 Surgical Management
Surgical intervention is indicated when there is inadequate improvement with antibiotics and/or evidence of an orbital abscess or progressive visual loss [21]. Surgical approaches for drainage of orbital abscess include opening the upper eyelid blepharoplasty incision, a Kronlein-Burke approach (lateral orbitotomy), an inferior transconjunctival incision, or a transantral (Cladwell Luc) approach [22]. The medial orbit may also be accessed through a transnasal endoscopic approach, but an abscess in this location is more likely to be related to sinus disease than blepharoplasty. In general, orbital abscess after blepharoplasty is very rare [23].
Fig. 11.6 Orbital cellulitis with proptosis and chemosis
Orbital cellulitis occurs when the infectious process involves the tissues posterior to the orbital septum. The clinical presentation differs from preseptal cellulitis by the hallmarks of increased pain, proptosis, restriction of ocular motility, chemosis, pupillary defects, dyschromatopsia, and loss of vision in addition to the findings seen in preseptal cellulitis (Fig. 11.6). The alterations in globe position and pupillary function should not be seen if the process is isolated to the preseptal space. The common organisms involved in orbital cellulitis are the same as those involved in preseptal cellulitis [20].
11.2.3.1 Medical Management
Preseptal cellulitis is initially managed with oral antibiotics and clinical monitoring. The patient typically shows signs of improvement in the first 24–36 h. If patients with preseptal cellulitis do not improve within the expected time frame, or if they progress to orbital involvement, they are managed as a case of orbital cellulitis.
Orbital cellulitis is a more serious infection, and early recognition and treatment is important to prevent further complications, such as subperiosteal abscess, orbital abscess, cavernous sinus thrombosis, optic nerve compression, meningitis, panophthalmitis, brain abscess, or vision loss [21]. In cases of orbital cellulitis, the patient is admitted to the hospital for close observation, CT imaging of orbits and brain, blood cultures, and immediate initiation of intravenous (IV) broad-spectrum antibiotics [13, 20]. It is important that any other aspect of the patient’s treatment does not delay the administration of antibiotics. The patient is monitored for
11.3Surgical Complications
11.3.1 Lagophthalmos
Incomplete closure of the eyelids, lagophthalmos, can be a temporary or permanent sequela of upper blepharoplasty (Fig. 11.7). Transient lagophthalmous is related to postoperative edema and/or a reduction in orbicularis muscle tone secondary to local anesthetic or manipulation. The condition typically resolves spontaneously within the first 1–2 weeks postoperatively. Persistent lagophthalmous can be caused by excessive skin removal, incarceration of the orbital septum into the wound closure with resultant septal adhesions, or trauma to the orbicularis muscle or peripheral seventh cranial nerve. Symptoms of lagophthalmos may include foreign body sensation, blurred vision, burning, tearing, and red eye. The clinical findings can include conjunctival injection, lid edema, corneal staining with fluorescein (superficial punctate keratopathy), or rarely, corneal ulceration. When the eyelids do not close completely, the cornea is partially exposed, and in severe cases, exposure can give rise to corneal ulceration with infection and/or scarring. Prior to performing upper blepharoplasty surgery, patients are assessed for dry eye syndrome, history of previous laser in situ keratomileusis (LASIK), and adequacy of Bell’s reflex. Patients with preexisting dry eye syndrome or previous LASIK are at greater risk from the complications of lagophthalmos [24].
11.3.1.1 Medical Management
Initial treatment for lagophthalmos should consist of gentle massage/stretching of the eyelids and aggressive lubrication