Rifle Blast Exacerbating Hearing Loss in a Patient Treated With Teprotumumab for Thyroid Eye Disease.

Teprotumumab is a promising new immunomodulatory therapy for thyroid eye disease. One unique adverse effect observed in clinical trials was hearing impairment; however, all adverse auditory effects in prior clinical trials resolved spontaneously after completion of teprotumumab therapy. The authors present a case of a patient on teprotumumab for thyroid eye disease who experienced sustained hearing loss secondary to shooting a rifle without ear protection. In this case, it is suspected the teprotumumab infusions resulted in increased susceptibility of the inner ear hair cells to noise-induced trauma secondary to IGF-IR inhibition. Specific ear protection protocols may need to be implemented in the future for patients on teprotumumab therapy to prevent sustained hearing loss, especially for susceptible patient populations.

Orbital Fractures and Associated Ocular Injuries in Operation Iraqi Freedom and Operation Enduring Freedom Referred to a Tertiary Care Military Hospital and the Effect on Final Visual Acuity.

PURPOSE: To update the incidence of orbital fractures in U.S. Soldiers admitted to the former Walter Reed Army Medical Center from 2001 to 2011 after sustaining combat injuries in Operation Iraqi Freedom and Operation Enduring Freedom. METHODS: Data were collected in the Walter Reed Ocular Trauma Database. Inclusion criteria were any U.S. Soldier or Department of Defense civilian with an orbital fracture injured in Operation Iraqi Freedom/Operation Enduring Freedom. Primary outcome measures were final visual acuity and the effect of orbital fracture, number of fractures, and anatomic location of fracture on final visual acuity. RESULTS: Eight-hundred ninety eye injuries occurred in 652 patients evacuated to Walter Reed Army Medical Center between 2001 and 2011. Orbital fractures occurred in 304 eyes (34.2%). A single wall was fractured in 140 eyes (46.05%), 2 in 99 (32.6%) eyes, 3 in 31 (10.2%), 4 in 28 (9.2%), and unknown in 6 (1.9%) eyes. Roof fractures were found in 74 (24.34%), medial wall in 135 (44.41%), lateral wall in 109 (35.9%), and floor fractures in 217 (71.4%). Final visual acuity was analyzed and 140 (46.05%) eyes had greater than 20/40 vision, 17 (5.59%) were 20/50 to 20/200, 26 (8.5%) were count fingers to light perception, and 95 (31.3%) were no light perception. In logistic regression analysis, roof (p = 0.001), medial (p = 0.009), and lateral fractures (p = 0.016) were significantly associated with final visual acuity less than 20/200, while floor fractures were not (p = 0.874). Orbital fracture and all fracture subtypes were significantly associated with traumatic brain injury, retrobulbar hematoma, optic nerve injury, but not for vitreous hemorrhage, commotio, hyphema, and choroidal rupture. Fracture repair was noted in 45 (14.8%). CONCLUSIONS: Orbital fractures occurred in a third of Operation Iraqi Freedom/Operation Enduring Freedom eyes of ocular trauma patients referred to one tertiary care military hospital. This resulted in approximately 40% of these eyes remaining legally blind after injury.Orbital fractures occur commonly during combat trauma and a significant number are legally blind despite appropriate treatment.

Lateral Canthotomy and Cantholysis in Operations Iraqi Freedom and Enduring Freedom: 2001-2011.

PURPOSE: To describe outcomes and associated ocular injuries of lateral canthotomy and cantholysis (LCC) as performed in combat ocular trauma. METHODS: Data from the Walter Reed Ocular Trauma Database of patients requiring LCC during Operations Iraqi Freedom and Enduring Freedom was reviewed as a retrospective cohort. Primary outcome measures included final visual acuity (VA) and Ocular Trauma Score. Secondary outcome measures were associated injuries and timing of surgery. RESULTS: Thirty-six LCCs were recorded on a total of 890 eyes (4.04 %) in the Walter Reed Ocular Trauma Database. Eighteen out of 36 eyes (50.00%) had a final VA of the affected eye of 20/200 or worse vision. From the initial available VA measured either at the time of injury or at Walter Reed Army Medical Center, 13 eyes (40.63%) had no change in VA, 15 eyes (46.88%) had improvement, and 4 (12.5%) had a decrease in VA (n = 32, data unavailable for 4 eyes). Ocular Trauma score 0-65 was noted in 14 (38.9%) and 66-100 (61.1%). Retinal detachment (6, 16.67%), optic nerve injuries (7, 19.44%), orbital fractures (20, 55.56%), and retrobulbar hematoma (25, 69.44%) were commonly associated injuries. Of the 36 LCC, 18 (50.00%) were performed as the first surgery performed at the combat support hospital, 13 (36.11%) as the second, 4 (11.11%) as the third, and 1 (2.78%) as the fourth. CONCLUSIONS: The largest subgroup of patients had an improvement in VA associated with performance of LCC; however, half of patients remained with a final VA of equal to or worse than 20/200 due to severe ocular trauma.

Enucleations and Eviscerations for Combat Ocular Trauma Performed During Operations Iraqi and Enduring Freedom: 2001 to 2011.

PURPOSE: To describe the demographics and clinical outcomes of patients who underwent posttraumatic enucleation or evisceration during Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF) from 2001 to 2011. METHODS: The Walter Reed Ocular Trauma Database is a retrospective case series of US Servicemembers and Department of Defense civilians who had combat ocular injuries in OIF and OEF. Data regarding posttraumatic enucleations and eviscerations performed during OIF and OEF were extracted. The main outcomes analyzed were the number of enucleations and eviscerations performed, location of the surgery, laterality, and graft type. The secondary outcome measures included: mechanism of injury and Ocular Trauma Score classification. RESULTS: One hundred nine enucleations and eviscerations were performed on the 890 eyes (12.24%). Sixty-three (57.80%) primary enucleations, 36 (33.03%) secondary enucleations, 5 (4.59%) postretinal detachment repair enucleations, and 5 (4.59%) primary eviscerations were completed. The surgeries were completed at a combat support hospital (57; 52.3%), or Walter Reed Army Medical Center (49; 45.0%). All surgeries were unilateral except in 2 patients. The most common graft type used was silicone (n = 56; 51.38%). Improvised explosive devices caused 76 (69.72%) eye injuries. Ocular Trauma Score were recorded as 56 (51.38%) between 0 and 44, 44 (40.37%) between 45 and 65, and unknown in 9 (8.26%). CONCLUSION: Posttraumatic enucleation or evisceration due to devastating ocular trauma is required in about 15% of ophthalmic patients in modern combat trauma. The psychosocial impact on veterans who have required an enucleation or evisceration from combat trauma has been poorly studied and requires further review.

Cicatricial Ectropion Secondary to Graft-Versus-Host Disease.

Ocular complications of graft-versus-host disease are well documented. While skin changes due to graft-versus-host disease have been mentioned in the literature, cicatricial ectropion has not been previous reported. The authors present a case of a 31-year-old male with cicatricial ectropion secondary to graft-versus-host disease requiring treatment with a full thickness skin graft.

Fibrous Histiocytoma of the Lacrimal Sac in an 11-Year-Old Male.

Fibrous histiocytoma is a soft tissue tumor with cells resembling both fibroblasts and histiocytes. Occasionally in the orbit, they rarely arise in the lacrimal sac. Similar to prior cases described, the patient presented with symptoms of epiphora and a slowly enlarging mass inferior to the right medial canthus. Imaging demonstrated a circumscribed 1.2 cm × 1.1 cm × 1.1 cm mass within the lacrimal sac without surrounding bony destruction. Grossly, the tumor appeared homogenous and rubbery. Pathologic study results from the case demonstrated zones of hypercellularity and hypocellularity with a fibrous appearance, admixed with spindle cells and collections of foamy histiocytes. A diagnosis of benign fibrous histiocytoma was rendered, with the patient experiencing a complete resolution of symptoms at subsequent follow up. To the authors' knowledge, this is the first reported solitary case report of a fibrous histiocytoma of the lacrimal sac in a pediatric patient.

Ophthalmic Manifestations of Facial Dog Bites in Children.

PURPOSE: To characterize ophthalmic manifestations and periocular injuries of pediatric facial dog bites. METHODS: A retrospective review of all children younger than 18 years who sought medical attention after a dog bite to the face between January 1, 2003 and May 22, 2014 was performed at a large tertiary pediatric hospital. Data on type and location of injury, surgical intervention, and complications were collected. RESULTS: A total of 1,989 children aged 0.19 to 17 years were identified with dog bites. Dog bites to the face occurred in most patients (n = 1, 414 [71%]). Of those children with facial dog bite injuries, 230 (16%) suffered ophthalmic manifestations. The average age was 4.3 years. Eyelid injuries occurred in 227 (99%) of children, 47 (20%) sustained canalicular system injuries, 3 (1.3%) suffered corneal abrasions, and 2 patients sustained facial nerve injury resulting in lagophthalmos. No patients suffered vision loss. Complications occurred in 32 patients (14%), with the most common being epiphora in 9 patients (28%), upper eyelid ptosis in 8 (25%), and prominent scar formation in 4 patients (13%). Thirteen children (5.7%) needed one or more secondary procedure to correct complications. CONCLUSIONS: The authors report the clinical features and management on the largest series of ophthalmic and periocular injuries associated with pediatric facial dog bites. These injuries occur in about 1 in 6 dog bites to the face and primarily involve the ocular adnexa. Despite early and appropriate surgical management, complications and the need for revision surgery are relatively common.

Increased Incidence of Rhino-Orbital-Cerebral Mucormycosis After Colorado Flooding.

In September 2013, central Colorado experienced a record amount of rainfall resulting in widespread flooding. Within 1 month of the flooding, 4 patients presented to the authors' institution with rhino-orbital-cerebral mucormycosis. This represents the largest number of cases ever recorded over a 1-month period. The authors hypothesize that the combination of immunocompromised status and environmental exposure resulted in the increased incidence.

Concurrent Endophthalmitis and Orbital Cellulitis From Metastatic Klebsiella pneumonia Liver Abscess.

A 70-year-old Korean female with a history of Klebsiella pneumonia liver abscess was presented to the authors' service with signs of endophthalmitis and orbital cellulitis. Vitreous biopsy confirmed K. pneumonia as the causative organism. With prolonged intravenous antibiotics and steroids, orbital symptoms resolved, but visual acuity remained at light perception. This is the first case in the literature to report on endophthalmitis and orbital cellulitis from K. pneumonia liver abscess.

Dacryocystitis As the Initial Presentation of Invasive Fungal Sinusitis in Immunocompromised Children.

Sino-orbital fungal infection is a rare, but life-threatening disease seen mainly in immunocompromised patients. While initial clinical impression may vary, dacryocystitis has rarely been described as the initial presenting sign. The authors present 2 pediatric cases of dacryocystitis as the initial sign of invasive fungal sinusitis. To their knowledge, this presenting sign has not been previously reported in the pediatric population. Management strategies and outcomes are discussed.

Axial Globe Position Measurement: A Prospective Multicenter Study by the International Thyroid Eye Disease Society.

PURPOSE: Identify a reproducible measure of axial globe position (AGP) for multicenter studies on patients with thyroid eye disease (TED). METHODS: This is a prospective, international, multicenter, observational study in which 3 types of AGP evaluation were examined: radiologic, clinical, and photographic. In this study, CT was the modality to which all other methods were compared. CT AGP was measured from an orthogonal line between the anterior lateral orbital rims to the cornea. All CT measurements were made at a single institution by 3 individual clinicians. Clinical evaluation was performed with exophthalmometry. Three clinicians from each clinical site assessed AGP with 3 different exophthalmometers and horizontal palpebral width using a ruler. Each physician made 3 separate measurements with each type of exophthalmometer not in succession. All photographic measurements were made at a single institution. AGP was measured from lateral photographs in which a standard marker was placed at the anterior lateral orbital rim. Horizontal and vertical palpebral fissure were measured from frontal photographs. Three trained readers measured 3 separate times not in succession. Exophthalmometry and photography method validity was assessed by agreement with CT (mean differences calculation, intraclass correlation coefficients [ICCs], Bland-Altman figures). Correlation between palpebral fissure and CT AGP was assessed with Pearson correlation. Intraclinician and interclinician reliability was evaluated using ICCs. RESULTS: Sixty-eight patients from 7 centers participated. CT mean AGP was 21.37 mm (15.96-28.90 mm) right and 21.22 mm (15.87-28.70 mm) left (ICC 0.996 and 0.995). Exophthalmometry AGP fell between 18 mm and 25 mm. Intraclinician agreement across exophthalmometers was ideal (ICC 0.948-0.983). Agreement between clinicians was greater than 0.85 for all upright exophthalmometry measurements. Photographic mean AGP was 20.47 mm (10.92-30.88 mm) right and 20.30 mm (8.61-28.72 mm) left. Intrareader and interreader agreement was ideal (ICC 0.991-0.989). All exophthalmometers' mean differences from CT ranged between -0.06 mm (±1.36 mm) and 0.54 mm (±1.61 mm); 95% confidence interval fell within 1 mm. Magnitude of AGP did not affect exophthalmometry validity. Oculus best estimated CT AGP but differences from other exophthalmometers were not clinically meaningful in upright measurements. Photographic AGP (right ICC = 0.575, left ICC = 0.355) and palpebral fissure do not agree with CT. CONCLUSIONS: Upright clinical exophthalmometry accurately estimates CT AGP in TED. AGP measurement was reliably reproduced by the same clinician and between clinicians at multiple institutions using the protocol in this study. These findings allow reliable measurement of AGP that will be of considerable value in future outcome studies.

C-Reactive Protein As a Marker for Initiating Steroid Treatment in Children With Orbital Cellulitis.

PURPOSE: To determine both the benefit of systemic steroids in pediatric patients with orbital cellulitis and to assess the usefulness of C-reactive protein (CRP) levels as a marker for starting steroids. METHODS: Prospective, comparative interventional study. Pediatric patients aged 1 to 18 years admitted to a tertiary care children's hospital with a diagnosis of orbital cellulitis from October 2012 to March 2014 were included in the study. All patients were treated with intravenous antibiotics, and patients with subperiosteal abscess who met previously published criteria for surgical decompression underwent combined transorbital drainage and/or endoscopic sinus surgery. CRP was measured daily as a biomarker of inflammation, and when below 4 mg/dl, patients were started on oral prednisone 1 mg/kg per day for 7 days. Patients whose families did not consent to steroid treatment served as the control group. Patients were followed after discharge until symptoms resolved and all medications were discontinued. RESULTS: Thirty-one children were diagnosed with orbital cellulitis during the study period. Of these 31 children, 24 received oral steroids (77%) and 7 did not (23%). There were 19 males and 5 females in the steroid group with an average age of 8.1 years, and 6 males and 1 female in the nonsteroid group with an average age of 7.1 years (p = 0.618). Thirteen patients (54%) in the steroid group and 2 patients (29%) in the nonsteroid group underwent sinus surgery with or without orbitotomy (p = 0.394). The average CRP at the onset of steroid treatment was 2.8 mg/dl (range: 0.5-4). Patients who received oral steroids were admitted for an average of 3.96 days. In comparison, patients who did not receive steroids were admitted for an average of 7.17 days (p < 0.05). Once CRP was ≤4 mg/dl, patients treated with steroids remained in the hospital for another 1.1 days, while patients who did not receive steroids remained hospitalized for another 4.9 days (p < 0.01). In the steroid group, 2 families reported increased hyperactivity in their children while on steroids. There was 1 case in each group of recurrence of symptoms after discharge from the hospital. Average follow-up time was 2.4 months in the steroid group and 2 months in the nonsteroid group (p = 0.996). At last visit, all patients returned to their baseline ophthalmic examination. There were no cases of vision loss or permanent ocular disability in either group. CONCLUSIONS: Our results give further evidence of the safety and benefit of systemic steroids in children with orbital cellulitis. Futhermore, this is the first study to suggest a standardized starting point (CRP ≤ 4 mg/dl) and dosing schedule (oral prednisone 1 mg/kg for 7 days) for children with orbital cellulitis. Patients who received systemic steroids after CRP dropped below 4 mg/dl were discharged from the hospital earlier than patients who did not receive systemic steroids.

Perioperative pregabalin for attenuation of postoperative pain after eyelid surgery.

PURPOSE: To examine the effect of a 1-time dose of pregabalin (Lyrica) on the perception of pain and analgesic consumption after oculofacial plastic surgery. METHODS: In this prospective, randomized, double-blind, placebo-controlled trial, patients presenting to the oculofacial plastic surgery service at University of Colorado Eye Center for functional eyelid surgery and who met the study criteria were consecutively enrolled between October 2011 and September 2012. Subjects were randomized to either placebo or 150 mg pregabalin administered 15 minutes to an hour prior to the procedure. The procedure was then performed under the usual standard of care. Postoperatively, study subjects recorded pain scores on visual analog scales (range 0-100) at 1 to 2 hours, 2 to 4 hours, 8 to 12 hours, 20 to 28 hours, and 36 to 48 hours and the amount of acetaminophen consumed. Data were analyzed with Statistical Analysis System software using mixed-effects linear models. RESULTS: Fifty-two patients were enrolled. Three patients were excluded due to incomplete follow up (n = 2) and postoperative course requiring early unblinding (n = 1). Twenty-six subjects were men. Average age was 68 years (range, 25-89). Eyelid procedures performed included blepharoplasty (18), canthoplasty (11), ptosis repair (15), eyelid retraction repair (2), pentagonal wedge resection (1), and MOHS reconstruction (2). Twenty-six patients were randomized to receive pregabalin, while the remainder received placebo. There was no significant difference in demographics between the 2 groups. The pregabalin group reported pain scores that were 5.5 points lower on average compared with the placebo group (p = 0.0307). Patients in the pregabalin group also consumed half as much acetaminophen (1.3 g) on average as the placebo group (2.6 g) during the postoperative period. CONCLUSIONS: Pregabalin is effective in reducing postoperative pain after oculoplastic procedures when compared with placebo. It may be a useful adjunct for pain control in selected patients.

Tear Trough Incision for External Dacryocystorhinostomy.

PURPOSE: Scar formation is a frequently cited complication of external dacryocystorhinostomy (exDCR). The purpose of this study is to evaluate scar appearance after exDCR with the skin incision placed in the tear trough. METHODS: Multicenter, prospective, noncomparative interventional study was approved by the University of Colorado Institutional Review Board. Patients undergoing exDCR from February 2013 to January 2014 were included in the study, and surgeries were performed by all authors. The incision site for all patients started just under the medial canthal tendon and extended inferolaterally into the tear trough for 10 mm to 15 mm. External dacryocystorhinostomy was performed in the usual manner, and the incision was closed according to the surgeon's preference. At 3 months postop, all patients were asked to rate their scar on the basis of the following grading scale: 0, invisible incision; 1, minimally visible incision; 2, moderately visible incision; and 3, very visible incision. Functional success of the surgery was also determined by asking the patients if their symptoms resolved, improved, or did not change. External photographs taken at 3 months after surgery were graded by 3 independent oculofacial and facial plastic surgeons using the same grading scale. RESULTS: Seventy-two surgeries were performed in 68 consecutive exDCR patients with nasolacrimal duct obstruction during the study period. Sixty-nine out of 72 patients reported improved or resolved symptoms (95.8%). The average patient scar grade was 0.21, while the average surgeon scar grade was 0.99 (p < 0.001). Sixty out of the 72 patients graded the scar as invisible (83.3%), and only 3 patients graded the scar as moderately visible (4.2%). No patients graded the scar as very visible. Of the 216 surgeon grades, 55 scars were graded as invisible (25.5%), while 8 were graded as very visible (3.7%). CONCLUSIONS: Scar appearance after exDCR with the incision placed in the tear trough is minimally visible to surgeons, and more importantly, nearly invisible to patients.

Biodegradable Fixation of the Orbital Rim After Lateral Orbitotomy.

PURPOSE: To describe authors' experience with repair of the lateral orbital rim with poly-L/DL-lactic acid (PDLLA) biodegradable plates using ultrasonic pin fixation after lateral orbitotomy with bone flap. METHODS: The authors retrospectively reviewed all patients who underwent a lateral orbitotomy with bone flap for biopsy of orbital tumors at their institution from January 2010 to May 2013. All patients underwent an orbitotomy by either a lateral eyelid crease incision or lateral canthotomy/cantholysis approach. A lateral bone flap was fashioned in the usual manner, extending from the frontozygomatic suture down the lateral rim for approximately 2 cm. The bone flap was repaired in each case with either a 6 or 7 hole PDLLA plate and secured with ultrasonic PDLLA pin fixation. RESULTS: Twenty-four patients were identified who underwent a lateral orbitotomy with bone flap. Of these patients, 10 were repaired with PDLLA plates. The average age of the patients with PDLLA bone flap fixation was 55 years (range 5-85). The average follow-up time was 12.9 months (range 4-42). Indications included 4 lacrimal gland tumors, 4 intraconal tumors, and 2 lateral orbital tumors. Final diagnosis included lymphoma (3), squamous cell carcinoma (1), neuroblastoma (1), amyloid (1), fibrous tissue (1), sarcoidosis (1), cavernous hemangioma (1), and idiopathic orbital inflammation (1). Three patients had edema of the surrounding soft tissues after surgery, all but 1 resolved by postop month 3. There were 2 cases of transient temporal numbness that resolved by postop month 1. There were no cases of vision loss, extraocular motility deficit, infection, or need for removal of the implant before absorption. CONCLUSIONS: PDLLA biodegradable plates with ultrasonic pin placement provide a safe, effective means for lateral rim fixation after orbitotomy with bone flap.

Radiation-induced dedifferentiated chondrosarcoma with orbital invasion.

PURPOSE: To report 2 interventional cases of dedifferentiated chondrosarcoma with orbital involvement after radiotherapy performed in childhood and to review the literature on chondrosarcoma in the orbit following radiation treatment. METHODS: Retrospective analysis of medical records of 2 patients with chondrosarcoma of the orbits with review of the literature. RESULTS: The first patient developed chondrosarcoma of the orbital and maxillary sinus 36 years after external beam radiation therapy to the OS to treat retinoblastoma. The second patient developed a large orbital chondrosarcoma 35 years after external beam radiation therapy in the treatment of craniofacial fibrous dysplasia. CONCLUSIONS: These cases highlight the risk of secondary chondrosarcoma in patients following radiotherapy and the importance of lifetime monitoring.

A systematic approach to CT evaluation of orbital trauma.

Computed tomography (CT) is widely used in the initial evaluation of patients with craniofacial trauma. Due to anatomical proximity, craniofacial trauma often involves concomitant injury to the eye and orbit. These injuries may have devastating consequences to vision, ocular motility, and cosmesis. CT imaging provides a rapid and detailed evaluation of bony structures and soft tissues of the orbit, is sensitive in detection of orbital foreign bodies, and often guides clinical and surgical management decisions in orbital trauma. For this reason, radiologists should be prepared to rapidly recognize common orbital fracture patterns, accurately describe soft tissue injuries of the orbit, detect and localize retained foreign bodies within the globe and orbit, and recognize abnormalities of the contents and integrity of the globe. In this review, we present a systematic approach to assist radiologists in the rapid evaluation of orbital trauma using the "BALPINE" mnemonic-bones, anterior chamber, lens, posterior globe structures, intraconal orbit, neurovascular structures, and extraocular muscles/extraconal orbit. Using this approach, we describe common traumatic findings within each of these spaces, and present common postsurgical appearances that can mimic findings of acute trauma.

Bilateral Candida and atypical mycobacterial infection after frontalis sling suspension with silicone rod to correct congenital ptosis.

In this case report, the authors describe an unusual complication of a frontalis sling suspension with silicone rods. A 5-year-old girl with blepharophimosis syndrome underwent frontalis sling suspension using an open sky technique. Four weeks after surgery, she was noted to have pustules over both upper eyelids and eyebrows. Cultures from the surgical sites grew Mycobacterium chelonae and Candida parapsilosis. Intravenous antibiotics and antifungals and sling explantation were curative. One month after sling explantation, the patient maintained an adequate marginal reflex distance 1. Atypical mycobacterial and Candida infection should be considered in the differential diagnoses of postoperative infection after frontalis sling suspension with silicone rods.

Fusobacterium necrophorum Orbital Cellulitis With Intraconal Abscess.

A 19-year-old male presented to the emergency department with progressive right eye proptosis and was subsequently diagnosed with bacterial orbital cellulitis and acute on chronic allergic fungal sinusitis. He experienced brief symptomatic improvement after endoscopic sinus surgery, initiation of antibiotics, and steroid treatment; however, he re-presented five days after discharge with significantly worsened symptoms and no light perception in the right eye. Cultures resulted in Aspergillus and Fusobacterium necrophorum, a rare, aggressive etiology of bacterial orbital cellulitis. He developed an intraconal abscess requiring multiple orbitotomies for decompression and abscess drainage. To our knowledge, only eight prior cases of F. necrophorum orbital cellulitis have been reported in the literature (excluding the present case) and our patient is the first case of this organism causing an intraconal abscess. The authors discuss the importance of early recognition and close follow-up of F. necrophorum orbital infections.