a 10-year - old asian indian male child was brought to the emergency services of our tertiary care hospital with progressive bulging of the left eye for the past 7 days . it was associated with deep constant periorbital pain , inability to close the eye , fever with no rigors or chills , discharge , and decreased vision . the patient gave a history of scratching of boil over the left upper eyelid 3 days before start of symptoms . there was no history of upper respiratory tract infection , toothache , ear discharge , insect bite , or trauma . the patient had received oral penicillins before presentation at our center , but there was no relief . examination of the affected eye revealed visual acuity of 6/24 , hypoglobus , mechanical ptosis , restriction of ocular movements in all directions ; swelling of lids with overlying redness of skin with raised temperature and tenderness on palpation . anterior segment examination showed conjunctival chemosis and diffuse descemet folds while posterior segment examination was unremarkable . investigation showed hemoglobin of 13.6 g / dl , total leukocyte count of 12,500/mm , erythrocyte sedimentation rate of 45 mm in 1 h , and no pus cells in urine . noncontrast computerized tomography ( ncct ) scan showed ill - defined hypodense collection in the extraconal department of the left orbit , extending up to orbital septum and causing proptosis suggestive of orbital abscess . there was associated with thickening of superior rectus - levator palpebrae superioris ( sr - lps ) complex but no evidence of sinusitis [ fig . 1 ] . at presentation . ( a ) clinical picture , ( b ) ill - defined hypodense collection in the extraconal department of the orbit suggestive of orbital abscess , ( c ) thickening of superior rectus - levator palpebrae superioris complex , ( d ) clear sinuses on left a straightforward diagnosis of orbital cellulitis with abscess formation was made ; and intravenous amoxicillin ( 25 mg / kg / day in three divided doses ) and clavulanic acid and metronidazole ( 7.5 mg / kg / day in three divided doses ) and amikacin ( 15 mg / kg / day in three divided doses ) were started empirically . abscess was drained and pus samples were sent for microbiological examination . we were left in a fix when there was no improvement even after 3 days of treatment . microbiology report unveiled the mystery behind this odd behavior and guided us toward the correct path for further management . culture on blood agar showed greenish discoloration suggestive of alpha ( complete ) hemolysis while macconkey agar showed magenta - colored colonies . microscopy shows gram - positive spectacle - shaped cocci arranged at an angle to each other and in lines . the organism was catalase negative , grew on 6.5% sodium chloride , and produced black colonies on blood tellurite agar . sensitivity as per the clinical and laboratory standards institute revealed resistance to ciprofloxacin , penicillins , and cotrimoxazole and sensitivity to clindamycin , teicoplanin , linezolid , gentamicin , and doxycycline . after pediatric consultation , intravenous clindamycin ( 20 mg / kg / day in three divided doses ) and gentamicin ( 1.5 mg / kg / day in three divided doses ) were started . swelling and proptosis started reducing by day 2 of revised therapy . on day 10 , best - corrected visual acuity improved to 6/6 , swelling and proptosis disappeared , and extraocular movements became full and free . repeat ncct showed thickened lps - sr complex , with involvement of tendons suggestive of myositis [ fig . after 1 month of steroid treatment , there was improvement in the amount of ptosis [ fig . ( a ) greenish colonies on blood agar , ( b ) magenta colonies on macconkey agar , ( c ) black colonies on blood tellurite agar , ( d ) microscopy showing spectacle - shaped gram - positive cocci arranged at an angle to each other two weeks after treatment . ( a ) left persistent ptosis , ( b ) superior rectus - levator palpebrae superioris complex thickened with involvement of tendons . one month after treatment , ( c ) improving ptosis , ( d ) decreased thickness of superior rectus - levator palpebrae superioris complex after a thorough search of scientific literature , we could find only one case of orbital cellulitis caused by s. faecalis , reported by biedner et al . in 1986 . they reported a 2.5-month - old female who was hospitalized with septicemia , ethmoiditis , and orbital cellulitis and was managed with intravenous ampicillin . unlike the earlier reported case , our patient was healthy with no history of admission to a hospital . gamble suggested three routes for spread of infection : ( 1 ) extension from an adjacent tissue , ( 2 ) septicemia , or ( 3 ) a wound . in pediatric population , 90% of patients with orbital cellulitis have existing sinusitis while our patient had clear sinuses on ct scan . enterococcus is an emerging agent of upper and lower airway diseases , including paranasal sinuses . therefore , possibility of cases associated with e. faecalis which remained undiagnosed can not be ruled out . the undiagnosed cases may have simply responded to the therapy given , and no abscess formation may have taken place . enterococcus group was originally classified with streptococci as group d. lancefield classified hemolytic streptococci on the basis of nature of carbohydrate antigen on cell wall into twenty lancefield groups . on blood agar , they are usually nonhemolytic but may show alpha ( complete ) or beta ( incomplete ) hemolysis . on microscopy , they appear as oval cocci , arranged at an angle to each other or in lines . they can be distinguished from other streptococci as they grow in the presence of 40% bile , 6.5% nacl , 9.6 ph , at 45c , in 0.1% methylene blue and survive at 60c for 45 min . e. faecalis can be identified by its ability to produce black colonies on tellurite agar and ferment mannitol , sucrose , sorbitol , and esculin . chaudhry et al . in their review of 218 patients of orbital cellulitis reported 4 patients with persistent ptosis after resolution of orbital cellulitis and found delayed intervention to be the common factor . in our case , precise treatment was delayed for about 10 days pending the microbiological confirmation of the causative agent . thickening of lps - sr complex in our case suggests myositis of lps , which was responsible for persistence of ptosis . the material obtained from abscess drainage should be handled properly and sent for microbiological examination to identify the causative organism and sensitivity . this is especially important , like in our case , where the causative agent was an unusual one and would not have responded to the empirical therapy . an accurate diagnosis and early intervention are required to prevent the deadly complications of orbital cellulitis . we must understand that antibiotics need to be used judiciously to restrict the resistance being developed by the microbes .
orbital cellulitis is an infection of soft tissue behind the orbital septum . 
 common pathogens isolated include staphylococcus aureus , staphylococcus epidermidis , and streptococcus pneumoniae . 
 it is a straightforward diagnosis and usually responds to empirical treatment without any sequela . 
 we report a case of orbital cellulitis caused by enterococcus faecalis , which was complicated by myositis of levator palpebrae superioris . to the best of our knowledge , 
 only one case report exists dating way back to 1986 .