Atypical Presentations of Orbital Cellulitis

Caused by Methicillin-Resistant
Staphylococcus aureus
Marc T. Mathias, MD,1 Michael B. Horsley, MD,1 Louise A. Mawn, MD,2 Stephen J. Laquis, MD,3
Kenneth V. Cahill, MD,4 Jill Foster, MD,4 Malena M. Amato, MD,5 Vikram D. Durairaj, MD1

Purpose: To evaluate the epidemiologic and clinical features of orbital cellulitis caused by methicillin-
resistant Staphylococcus aureus (MRSA).
Design: Multicenter, retrospective case series.
Participants: Fifteen patients with culture-positive MRSA orbital cellulitis.
Methods: All recent cases of orbital cellulitis at several hospitals and surgical centers were reviewed, and
cases with culture-positive MRSA from aspirates were identified. The data collected and analyzed retrospectively
included patient demographics, medical history, presenting sign, imaging results, surgical procedure performed,
surgical culture results, visual acuity at presentation and last follow-up, and duration of antibiotics.
Main Outcome Measures: Presenting sign, radiographic evidence of paranasal sinus disease, radiographic
evidence of multiple orbital abscesses, presence or absence of antecedent upper respiratory infection, and final
visual acuity.
Results: Fifteen cases were identified. The mean patient age was 31.9 years (standard deviation, 24.2 years).
Lid swelling was the presenting sign in 14 of 15 patients. No patients had a preceding upper respiratory infection,
and only 1 patient had antecedent eyelid trauma. Only 3 of 15 patients had documented adjacent paranasal sinus
disease on imaging. Lacrimal gland abscess or dacryoadenitis was the presenting finding in 5 of 15 patients.
Multiple orbital abscesses were identified in 4 of 15 patients by computed tomography or magnetic resonance
imaging. Fourteen of 15 cases required surgical intervention. Four of 15 cases had loss of visual acuity to light
perception or worse. All 4 of these cases had a delay in referral for surgical intervention.
Conclusions: In these 15 patients with MRSA orbital cellulitis, the typical clinical setting of orbital cellulitis
was absent; chiefly, there was no identified antecedent upper respiratory illness, nor was there a preceding
traumatic injury. Lid swelling in the absence of recent upper respiratory illness, lacrimal gland focus, multiple
orbital abscesses, and lack of adjacent paranasal sinus disease may be predictive factors that suggest MRSA as
the causative organism of orbital cellulitis.
Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed
in this article. Ophthalmology 2012;119:1238 1243 2012 by the American Academy of Ophthalmology.

Orbital cellulitis can be a sight-threatening condition with
devastating visual sequelae. Before the introduction of the
HiB vaccine in 1985, Haemophilus influenzae type B was
the most common causative pathogen identified in cases of
orbital cellulitis.1 With the introduction of the vaccine,
Staphylococcus and Streptococcus species have emerged
as the predominant microbes isolated from culture results
of drained orbital abscesses associated with orbital cel-
lulitis.2 Recent studies have identified increasing resis-
tance of Staphylococcus species to the antibiotic methi-
cillin in both nosocomial and community-acquired infections,
such as skin and soft tissue infections.3 The emergence of
methicillin-resistant Staphylococcus aureus (MRSA) strains
has clinical importance because of the increasing virulence of
the organism, disease severity, and the proper selection of
initial empiric antibiotics. Paralleling this rise in incidence
of skin and soft tissue infections, there have been increasing
reports of MRSA as a causative agent in orbital cellulitis.2,4 8
A study by McKinley et al2 of 38 cases of pediatric orbital
cellulitis at a single institution in the United States found that
15 patients required only medical management, whereas 23
underwent surgical intervention. Of the patients who under-
went surgical drainage and culture analysis, 36% of the culture
samples demonstrated positive results for MRSA, which rep-
resented 73% of all S. aureus isolates. Although there have
been many small case reports, no large series of MRSA-related
orbital infections has been reported in the Medline-indexed
English literature. This study presents 15 cases of MRSA-
related orbital cellulitis and the associated clinical features. To
the authors knowledge, this is the largest reported case series
of MRSA-related orbital cellulitis. The authors hypothesize
that MRSA-related orbital cellulitis may present with some

1238 2012 by the American Academy of Ophthalmology ISSN 0161-6420/12/$see front matter
Published by Elsevier Inc. doi:10.1016/j.ophtha.2012.01.010
 Mathias et al MRSA Orbital Cellulitis
Figure 1. A, External photograph demonstrating right periorbital edema. B, Axial computed tomography image showing orbits with contrast demon-
strating lacrimal gland abscess.
distinctive clinical and radiographic features that should raise
suspicion for this organism and help to guide empiric antibiotic
selection.
Patients and Methods
The medical records of patients with orbital cellulitis managed by
ophthalmic plastic surgeons between January 2006 and April 2009
at several institutions in the United States were reviewed retro-
spectively. Inclusion criteria included patients with clinical evi-
dence of orbital cellulitis, culture-positive MRSA isolates, and
radiographic evidence of orbital cellulitis with or without a fluid
collection demonstrated by either computed tomography (CT) or
magnetic resonance imaging. Charts were reviewed for patient
demographics and medical history, presenting clinical sign, imag-
ing results, surgical procedure performed, surgical culture results,
visual acuity at presentation and last follow-up, and duration of
antibiotic treatment. Several representative cases are reviewed. A
search was performed of the Medline-indexed English literature
using keywords orbital cellulitis, methicillin-resistant Staphylo-
coccus aureus, and lacrimal abscess. This study was approved
by the institutional review board at the University of Colorado
Hospital.
Results
Selected Case Reports
Case 1. A 4-year-old girl sought treatment at the emergency
department with a 3-day history of right upper eyelid swelling and
fever. Before presentation she had been treated with 2 days of oral
amoxicillin-clavulanate for a diagnosis of preseptal cellulitis. She
previously was healthy, with a medical history significant for a
remote episode of acute otitis media, but otherwise she had no
recent upper respiratory infection or eyelid trauma. On examina-
tion she showed evidence of right-sided ocular motility limitation,
chemosis, and periorbital edema (Fig 1A). Visual acuity was
fix-and-follow in both eyes. An orbital CT with contrast demon-
strated an abscess in the area of the right lacrimal gland (Fig 1B).
There was no paranasal sinus disease. A right orbitotomy with
abscess drainage and lacrimal gland biopsy was performed. Intra-
operative cultures grew MRSA. She was treated with intravenous
vancomycin and meropenem, which subsequently was switched to
intravenous clindamycin and intravenous ceftriaxone, and com-
pleted a 4-week course. At follow-up 6 weeks later, her edema had
resolved, ocular motility was normal, and visual acuity was 20/20
at distance in both eyes.
Case 2. A 46-year-old white man sought treatment at the
emergency department with left periorbital edema and pain, as
well as a 2- to 3-day history of progressive vision loss. There was
no history of recent trauma or infections. He was admitted and
started on intravenous ampicillin-sulbactam and intravenous levo-
floxacin. He was evaluated by a general ophthalmologist who
diagnosed left preseptal cellulitis and performed irrigation and
debridement of a left upper eyelid abscess. Initial visual acuity was
20/40 in the left eye, but it deteriorated rapidly over 3 days, and an
emergent oculoplastics consultation was obtained. At that time, he
was found to have light perception vision, proptosis, motility
restriction, and an afferent pupillary defect in the left eye. An
orbital CT with contrast demonstrated a superomedial and infero-
lateral fluid collection in the left orbit (Fig 2A) associated with
optic nerve stretch and tenting of the globe (Fig 2B). A left
orbitotomy was performed with placement of 2 drains. Intraoper-
ative cultures grew MRSA. He completed a 4-week course of
intravenous vancomycin. Clinical resolution of the infection was
achieved, but vision remained light perception at follow-up 3.5
weeks later.
Case 3. A 19-month-old black boy sought treatment at the
emergency department for progressive left upper eyelid edema
and left eye proptosis (Fig 3A). He had been evaluated by an
outside emergency department 5 days prior, diagnosed with
conjunctivitis, and given a course of oral azithromycin and
topical sulfacetamide drops. Visual acuity was fix-and-follow in
both eyes. He was started on intravenous vancomycin, intrave-
nous clindamycin, and intravenous ampicillin-sulbactam. An
orbital CT with contrast demonstrated a rim-enhancing mass in
the superolateral aspect of the left orbit centered within the
lacrimal gland and causing inferior displacement of the globe
(Fig 3B). There was no paranasal sinus disease. An orbital
magnetic resonance imaging scan demonstrated adjacent en-
hancement of the bone, raising concern about osteomyelitis. A
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 Ophthalmology Volume 119, Number 6, June 2012

Figure 2. A, Coronal computed tomography image of the orbits with contrast demonstrating supertemporal intraorbital abscess. B, Axial computed
tomography image of the orbits with contrast demonstrating proptosis with optic nerve stretch and tenting of the globe.

superolateral orbitotomy with abscess drainage was performed.
Intraoperative cultures grew MRSA. He was treated with 2
weeks of intravenous clindamycin followed by 4 weeks of oral
clindamycin. The infection was resolved clinically on follow-up
6 weeks later, and visual acuity was fix-and-follow in both eyes.
Case 4. A 5-year-old white boy initially had erythema and
edema of the left upper eyelid (Fig 4A). He was seen by his
primary care physician, diagnosed with a stye, and treated with
oral amoxicillin-clavulanate. The erythema and edema continued
to progress over 4 days and he was admitted to an outside hospital
for preseptal cellulitis. Initial visual acuity was documented as
fix-and-follow in both eyes. He was started on intravenous vanco-
mycin and intravenous ceftriaxone. He continued to worsen clin-
ically and was transferred to another hospital for evaluation by the
oculoplastics service. An orbital CT with contrast revealed a
superior orbital fluid collection with inferior displacement of the
globe (Fig 4B). There was no paranasal sinus disease. An orbito-
tomy was performed with drainage of the superior abscess. Intra-
operative cultures grew MRSA. He completed a 3-week course of
oral clindamycin. At follow-up 3 weeks later, the pathologic
features had resolved clinically with visual acuity 20/20 in both
eyes.
Summary of Cases
Patient demographics, visual acuity at presentation and final
follow-up, diagnosis, surgical procedure, imaging findings, and length
of follow-up are presented in Table 1 (available at http://aaojournal.
org). The mean patient age was 31.9 years (standard deviation, 24.2
years). Six of 15 patients (40%) were in the pediatric age group, being
younger than 18 years, with the remainder comprising the adult
population. Four of 15 patients (27%) were black and 11 of 15 (73%)
were white. Of the 15 total patients in this series, 12 patients (80%)
were male. Average follow-up was 2.4 months (standard deviation,
2.2 months). Only 3 of 15 patients (20%) had documented paranasal
sinus disease on imaging. Of these, paranasal sinus disease was found
in 1 of 6 pediatric cases (17%) and in 2 of 9 adult cases (22%). Four
of 15 patients (27%) had evidence of multiple abscesses on imaging.
All cases of multiple orbital abscesses were in the adult population.
Five of 15 patients (33%) had a lacrimal gland focus of infection,

Figure 3. A, External photograph demonstrating left periorbital edema and erythema. B, Axial computed tomography image of the orbits with contrast
demonstrating lacrimal gland abscess and globe displacement.

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 Mathias et al MRSA Orbital Cellulitis
Figure 4. A, External photograph demonstrating left periorbital edema and erythema. B, Coronal computed tomography image of the orbits with contrast
demonstrating superior orbital fluid collection with no paranasal sinus disease.
including 4 patients with lacrimal gland abscess and 1 patient with
dacryoadenitis and orbital cellulitis. All cases of lacrimal gland ab-
scess were in the pediatric subgroup. Four of 15 (27%) had loss of
visual acuity to light perception or worse at final follow-up. All of
these cases were in the adult population, with none of the pediatric
subgroup of patients having significant loss of visual acuity. Fourteen
of 15 patients (93%) underwent surgical intervention. The only patient
who did not undergo surgical intervention was patient 6, who had
evidence of lacrimal gland enlargement and inflammation radiograph-
ically, but did not have evidence of frank orbital abscess. Copious
purulent material expressed from the lacrimal gland at the bedside
was found to demonstrate positive results for MRSA. All other culture
results were obtained from intraoperative aspirates. Presenting signs,
presence or absence of preceding upper respiratory infection, presence
or absence of preceding eyelid trauma, initial and final antibiotic
selection, and total length of antibiotics are presented in Table 2
(available at http://aaojournal.org). Eyelid swelling was the presenting
sign in 14 of 15 patients (93%), and no patient was documented to
have a preceding upper respiratory infection. Only 1 patient had a
history of recent eyelid trauma caused by an insect sting. Mean length
of antibiotics was 5.3 weeks (standard deviation, 3.3 weeks). Patient
2 was an outlier, receiving a 16-week antibiotic course, presumably
because of a complicated combined MRSA and Aspergillus sino-
orbital infection. When this patient was removed from the analysis,
the mean length of antibiotic treatment became 4.2 weeks.
Discussion
In the past decade, infections resulting from MRSA have
been arising with increasing frequency. A study by Moran et
al3 of skin and soft-tissue infections treated at 11 emergency
departments found that MRSA accounted for 59% of all
infections. A recent epidemiologic study from the National
Health and Nutrition Examination Survey found the inci-
dence of S. aureus colonization in the United States popu-
lation to be 31.6% and the incidence of MRSA carriers to be
0.84%.9 This rise in part may be the result of an increasing
incidence of community-acquired (CA) MRSA strains,
where previously these infections had been found predom-
inantly in the nosocomial setting. The definition of CA
MRSA has varied in the literature, but generally this term
refers to those patients in whom the infection develops
outside of the hospital environment and who lack the typical
risk factors associated with nosocomial infection.10 In the
ophthalmic literature, there have been increasing reports of
CA MRSA-related ocular infections.4,6 8 A review of MRSA
infections within a regional health system in Texas found that
both ophthalmic and nonophthalmic CA MRSA infections
increased each year between 2000 and 2004.8 The incidence of
CA MRSA orbital infections also has been reported to be
increasing outside of the United States.11,12 A study by Vaska
et al12 at a pediatric hospital in Australia found that CA
MRSA caused 4 of 9 cases (44%) of orbital cellulitis over
an 18-month period. With this evolving trend, there is
growing concern regarding increasing MRSA-related or-
bital infections.
In particular, there have been increasing reports of both orbital
and preseptal cellulitis caused by MRSA, which raises concerns
for empiric antibiotic coverage.2,48,1115 Miller et al5 recently
reported 9 cases of pediatric orbital cellulitis and found the pres-
ence of MRSA isolates in 4 of 9 cases (44.4%). In addition,
another recent report of the microbiologic features of pediatric
orbital cellulitis by McKinley et al2 identified MRSA in 36%
(8/23) of patients who underwent surgical drainage of orbital
abscess or sinus drainage. Large studies of the incidence of
MRSA-related orbital infections in the adult population are
lacking.
This study presents 15 cases of MRSA-related orbital
cellulitis, which to the authors knowledge is the largest
case series presented in the Medline-indexed English liter-
ature. Cases of orbital cellulitis caused by MRSA may
present with distinctive clinical and radiographic features
that can help to guide treatment decisions and empiric
antibiotic coverage. The present cases had rapidly evolving
eyelid lesions with lid swelling as the most common pre-
senting sign. Many of these patients described that they first
developed a boil/chalazia/stye-like change to the lids that
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 Ophthalmology Volume 119, Number 6, June 2012
steadily increased to profound orbital cellulitis with numer-
ous microabscesses seen along the lid margin. Most impor-
tantly, none of these patients had an antecedent upper re-
spiratory infection, and only 1 patient had a history of recent
eyelid trauma that could serve as a potential entry site for
bacterial infection.
In this study, only 1 of 6 pediatric patients (17%) and 2 of
9 adult patients (22%) had evidence of ipsilateral sinusitis on
radiographic imaging. The overall incidence of paranasal sinus
disease in both populations combined was 20%. In the pedi-
atric population in particular, prior studies have found the
cause of orbital cellulitis most frequently to involve the con-
tiguous extension from an infected paranasal sinus with for-
mation of a subperiosteal abscess.16 A recent study by Nag-
eswaran et al17 of orbital cellulitis in 41 children found
paranasal sinus disease in 100% and subperiosteal or orbital
abscess in 83%. A similar study by Ferguson and McNab18
found the incidence of sinusitis in 34 pediatric patients to be
91% and the incidence in 18 adults to be 50%. The overall lack
of paranasal sinus disease in the pediatric subpopulation of the
current study, compared with prior reports, suggests that in this
group, the absence of sinusitis should raise clinical suspicion
for MRSA. Recognition of the difference in presentation be-
tween sinusitis-related orbital cellulitis and MRSA orbital cel-
lulitis has profound implications for the approach to medical
and surgical management of orbital cellulitis in children.
Lacrimal gland abscesses were found to be a common
presentation, with 4 of 15 cases (27%) having an identifiable
abscess on imaging and a fifth case with evidence of dacryoad-
enitis and purulent lacrimal gland drainage, but no frank orbital
abscess. All patients with lacrimal gland abscess were in the
pediatric subgroup, and when this population is isolated, lac-
rimal gland abscess was a radiographic finding in 67% of
children in this study. Lacrimal gland abscesses are reported
only rarely in the literature.19 23 Of the cases that have been
reported, MRSA has not been reported to be cultured from any
of the abscesses undergoing surgical intervention. In addition,
only 1 previous report of lacrimal gland abscess in the pediatric
population was found in which S. aureus was cultured, al-
though the authors do not comment on whether this was a
resistant strain.19 To the authors knowledge, this report is the
largest series of lacrimal gland abscesses reported in the literature.
Multiple orbital abscesses also were fairly common in
this series, representing 27% (4/15) of cases. Orbital cellu-
litis complicated by multiple abscesses is reported sporad-
ically in the literature.24 Although there is no study in the
literature that estimates the frequency of this complication,
the incidence likely is relatively low based on the authors
previous clinical experience. Multiple abscesses on imaging
again should raise clinical suspicion for MRSA.
Several patients had an aggressive clinical course, with 27%
(4/15) of patients having a final visual acuity of light percep-
tion or worse. All of these patients seemed to have a delay in
referral for surgical intervention. One patient had a visual
acuity of counting fingers at 3 feet at final follow-up, but
best-corrected vision was believed to be limited by a previous
retinal detachment. A recent study by Seltz et al25 of 94
pediatric patients with orbital cellulitis identified 3 patients, or
3%, with some degree of permanent visual loss, although the
degree of visual compromise was not mentioned. In a prior
1242
study of 218 patients with orbital cellulitis in the middle
east, 9 eyes (4.3%) demonstrated complete loss of vision,
although these patients also were believed to have had a
delay in referral for treatment.26 The current patients had
a higher incidence of visual loss. Interestingly, all cases
of severe vision loss in this study were in the adult
population, with none of the pediatric cases having severe
permanent visual loss. Methicillin-resistant S. aureusrelated
orbital infections may have a more aggressive disease course,
and immediate surgical intervention with empiric antibiotic
coverage is warranted when MRSA is suspected.
Several limitations of this study should be noted. This was
a retrospective review of cases of orbital cellulitis from the
practices of ophthalmic plastic surgeons. There is selection
bias in these cases because each was severe enough to warrant
subspecialty referral. In addition, inclusion criteria included
those patients with a severe enough clinical course to warrant
imaging with either CT or magnetic resonance imaging, as
well as cases severe enough to undergo operative intervention
with surgical aspiration of culture-positive MRSA orbital ab-
scesses. Milder cases might not have been imaged or have
undergone operative intervention. Although 14 of 15 patients
(93%) in this study underwent surgical intervention, the study
was designed to include only those patients who had culture-
positive MRSA, which requires surgical intervention to obtain
in most cases. It is difficult to draw any conclusions regarding
the percentage of MRSA orbital cellulitis cases that ultimately
require surgical intervention versus those that can be managed
medically or to compare that percentage with nonMRSA-
related orbital infections. Garcia and Harris27 previously pub-
lished a report of the indications for surgical intervention in
cases of orbital cellulitis complicated by subperiosteal abscess.
Indications for surgery in that study involved 9 criteria, includ-
ing age older than 9 years and nonmedial location of subperi-
osteal abscess. Of the 29 patients in that study who met criteria
for nonsurgical management, 93.1% had resolution of abscess
with medical therapy alone. In the current study, by these
criteria all adults would have met indications for surgery, and
4 of 6 of the pediatric patients would have met criteria based on
the data collected for review. The small number of patients
included in this series also limits conclusions that can be
generalized. A larger study would provide more powerful data
regarding the clinical characteristics and optimal management
strategies.
As previously described, the incidence of MRSA-
related orbital infections is increasing,2,8 and several
recent reports suggest that MRSA is becoming an impor-
tant pathogen in the development of orbital cellulitis,
necessitating consideration of this organism in both the
adult and pediatric populations.4 7 In this series of pa-
tients with MRSA-related orbital cellulitis, there were
distinctive features that are notable. Specifically, these
patients had clinical and radiographic features typically
not seen in orbital cellulitis. There was development of
eyelid swelling in the absence of a preceding upper
respiratory illness or a traumatic skin injury. Only a small
percentage of patients were found to have adjacent para-
nasal sinusitis, specifically only 17% in the pediatric
population and 22% in the adult population. There also
was a high percentage of lacrimal gland abscesses in the
 Mathias et al MRSA Orbital Cellulitis
pediatric subgroup. Lack of paranasal sinus disease, es-
pecially in the pediatric population, lack of preceding
periorbital trauma or antecedent upper respiratory infec-
tion associated lacrimal gland focus, and multiple orbital
abscesses should raise clinical suspicion for MRSA-
related orbital infection and should be considered for
immediate surgical drainage of any focal abscess as well
as appropriate empiric antibiotic coverage.
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Footnotes and Financial Disclosures
Originally received: June 8, 2011.
Final revision: December 30, 2011.
Accepted: January 6, 2012.
Available online: March 9, 2012. Manuscript no. 2011-843.
1
Rocky Mountain Lions Eye Institute, University of Colorado, Denver,
Colorado.
2
Vanderbilt Eye Institute, Vanderbilt University School of Medicine,
Nashville, Tennessee.
3
Bonita Springs, Florida.
4
Havener Eye Institute, Ohio State University, Columbus, Ohio.
5
Department of Ophthalmology, Haywood/Freemont Medical Centers, Union
City, California.
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Presented as a poster at: American Academy of Ophthalmology Annual
Meeting, October 2009, San Francisco, California.
Financial Disclosure(s):
The author(s) have no proprietary or commercial interest in any materials
discussed in this article.
Supported by the National Institutes of Health (grant no.: 1R21RR025806
[LAW]); an unrestricted grant to the Vanderbilt Eye Institute from Re-
search to Prevent Blindness, Inc., New York, New York; and a Research to
Prevent Blindness Physician Scientist Award (LAW). The sponsor or
funding organization had no role in the design or conduct of this research.
Correspondence:
Vikram D. Durairaj, MD, Department of Ophthalmology, University of Colorado
Denver, Anschutz Medical Campus, 1675 Aurora Court, Mail Stop F-731, Aurora,
CO 80045. E-mail: Vikram.Durairaj@ucdenver.edu.
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