Orbital Cellulitis Following Uncomplicated Aqueous Shunt Surgery

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To the Editor:
It was with great interest we read the article titled “Orbital cellulitis following uncomplicated aqueous shunt surgery” by Beck et al.1 We have few observations to make regarding this article.
Apart from the 5 case reports mentioned by the authors, 2 more cases of orbital cellulitis associated with aqueous drainage device (ADD) have been reported.2,3 Kassam et al2 reported concurrent endophthalmitis with orbital cellulitis in a 3-year-old boy with congenital glaucoma which was treated with ADD removal along with intravitreal, intravenous, and topical antibiotics. Farid et al3 have reported orbital cellulitis in an 11-month-old girl which progressed to endophthalmitis.
To find out source of infection we would like to know if blood cultures were performed. Also whether culture of the supramid suture was done as the patient had developed early signs of intraocular inflammation 2 days after admission. Various routes of infection have been described in literature such as tube-related conjunctival erosions, endophthalmitis progressing to orbital cellulitis, sinusitis, and endogenous infections.2 Author’s case had an intact conjunctiva and no evidence of sinusitis or endophthalmitis to begin with. Blood and suture culture could have been beneficial in finding out source and causative organism of this infection.
In view of the potential vision threatening complications of orbital cellulitis in ADD patients, the initial intravenous antibiotic coverage should be broad spectrum covering gram positive, gram negative, and anaerobic organisms. In addition to intravenous coamoxiclav, cephalosporins with gram negative bacterial coverage and metronidazole for anaerobic organisms should be considered as part of empiric therapy regimen.
We would also like to know if computed tomographic scans revealed any opacification or fluid collection around ADD suggestive of pus pockets. Presence of pus pocket is an indication of immediate surgical removal of the implant.2–4 Posttreatment computed tomographic scans would have been helpful to assess resolution of infection apart from clinical examination findings.
We agree with the authors that early presentation and prompt intervention lead to quick resolution of infection and the need for ADD removal was alleviated.
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