Sir,

Exudative retinal detachment (ERD) may result from the accumulation of fluid in the subretinal space because of hydrostatic factors (eg severe acute hypertension), inflammation, or neoplastic effusions.1 ERD generally resolves with successful treatment of the underlying disease, and visual recovery may be excellent.1, 2, 3

Case report

An 89-year-old male with chronic myeloid leukemia (CML) was referred with new onset RE pain and severe reduction of vision 1 week after admission for his CML. He was febrile (39 °C), anemic, and presented generalized malaise. He had bilateral age macular degeneration (AMD) that was worse in the RE.

On examination there was RE proptosis with limited lateral gaze, significant pain with retropulsion, right eyelid erythema and swelling, chemosis, and purulent discharge (Figure 1a). Visual acuity (VA) was light perception in the RE and 6/9 in the LE. The intraocular pressures were 34 mm Hg in the RE and 17 mm Hg in the LE. Fundoscopy revealed a RE ERD with shifting fluid, in the absence of PVD or retinal tears.

Figure 1
figure 1

(a) Magnetic resonance imaging (MRI) demonstrating right eye proptosis, swelling of the extraocular muscles, and the orbital fat, which all led to the diagnosis of orbital cellulitis. In addition, the exudative retinal detachment (ERD) is depicted in the MRI scan. Sinusitis is also evident. (b) MRI on day 10 post initiation of treatment demonstrating complete resolution of orbital cellulitis and no signs of ERD.

Full size image

On full blood count there was neutrophilic leucocytosis (WBC 22.79 × 103/μl; 94.2% neutrophils). C-reactive protein was 128 mg/l and ESR 106 mm/h. Culture of nasal aspirates revealed methicillin staph aureus (MRSA) and Warneri-Staph.

The patient was placed on intravenous (vancomycin, cefurixime, and metronidazole) and topical antibiotics. Symptoms improved by the fifth post-treatment day and blood tests gradually normalized. Complete resolution of the ERD was evident (Figure 1b). VA improved to 6/36.

Comment

Orbital cellulitis is an extremely rare cause of ERD. The only published reports4, 5 refer to a 12-year-old boy who sustained ERD due to orbital cellulitis originating from an eyelid abscess and a 56-year-old with Down’s syndrome; the source of infection remained unclear. In our case the MRI findings and the purulent nasal discharge were consistent with ethmoid sinusitis leading to cellulitis. The bacteria responsible for causing the infection are MRSA as the patient was hospitalized, and the nasal aspirate cultures were positive for MRSA. In all cases including ours treatment of cellulitis was followed by rapid resolution of the ERD.

Our case illustrates the uncommon but possible occurrence of ERD in the course of orbital cellulitis. Although the incidence is rare, it may pose diagnostic and therapeutic dilemmas, but it should be considered, especially in immunocompromised patients. Our case illustrates that medical management with strong antibiotics can lead to resolution without surgical intervention even in the presence of sinusitis.