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Septic Cavernous Sinus Thrombosis Associated With Orbital Cellulitis

A Report of 6 Cases and Review of Literature

Branson, Sara V., M.D.*; McClintic, Elysa, M.D.; Yeatts, R. Patrick, M.D.

Ophthalmic Plastic & Reconstructive Surgery: May/June 2019 - Volume 35 - Issue 3 - p 272–280
doi: 10.1097/IOP.0000000000001231
Original Investigations

Purpose: To describe risk factors, clinical parameters, treatment, and prognosis for patients with septic cavernous sinus thrombosis presenting with orbital cellulitis.

Methods: Retrospective case series of 6 patients identified with septic cavernous sinus thrombosis and orbital cellulitis confirmed by magnetic resonance imaging at a tertiary care center from January 1980 to December 2016. Medical records were reviewed for demographics, risk factors, symptoms, etiology, radiographic diagnosis, complications, treatments, and outcomes. In addition, a literature review was performed from 2005 to 2018, and 119 cases of septic cavernous sinus thrombosis confirmed by imaging were included for aggregate comparison. This study adheres to the tenets of the Declaration of Helsinki, and institutional review board approval was obtained.

Results: All 6 cases presented with headache, fever, ocular motility deficit, periorbital edema, and proptosis. The primary source of infection included sinusitis (n = 4) and bacteremia (n = 2). Identified microorganisms included methicillin resistant Staphylococcus aureus (n = 3) and Streptococcus anginosus (n = 1). All cases were treated with broad-spectrum intravenous antibiotics and anticoagulation, and one case underwent endoscopic sinus surgery. The mean time between initial presentation to diagnosis of cavernous sinus thrombosis was 2.8 days, and the average length of hospital admission was 21 days. The mortality rate was 0%, but 4 cases were discharged with neurological deficits including vision loss (n = 1) and ocular motility disturbance (n = 3). Literature review produced an additional 119 cases.

Conclusions: Early diagnostic imaging with contrast-enhanced CT or MRI should be initiated in patients with risk factors and ocular symptoms concerning for cavernous sinus thrombosis. Treatment entails early administration of broad-spectrum intravenous antibiotics, anticoagulation, and surgical drainage when applicable.

Six cases of septic cavernous sinus thrombosis were reviewed to highlight the diagnosis, complications, and treatment of this rare but deadly complication of infections originating from the orbit, sinuses, and midface.

*Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, U.S.A.

Department of Ophthalmology, Guthrie Clinic, Sayre, Pennsylvania, U.S.A.

Department of Ophthalmology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, U.S.A.

Accepted for publication July 31, 2018.

The authors have no financial or conflicts of interest to disclose.

Presented as a poster at the American Academy of Ophthalmology Annual Meeting on October 16, 2016 in Chicago, IL.

Address correspondence and reprint requests to R. Patrick Yeatts, M.D., Wake Forest University Eye Center, Janeway Clincal Science Building, 6th flr, Medical Center Blvd, Winston-Salem, NC 27157. E-mail:

© 2019 by The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc., All rights reserved.