Author:
ShariSchabowski
LotiffaColibao
Description
- An inflammatory, typically infectious condition affecting the eyelid(s)
- It is anatomically distinguished by its location, isolated to the tissues anterior to the orbital septum:
- Orbital septum is the connective tissue extension of the orbital periosteum that is reflected into the upper and lower eyelids
- Extension to the deep tissues is rare because the septum represents a nearly impenetrable barrier but it may be incomplete
- Most commonly presents as a complication of upper respiratory tract infection (URTI) and sinusitis:
- Swelling is caused by inflammatory edema from vascular and lymphatic congestion
- May occur as a complication of a localized inflammation/infection in the eyelid or adjacent structures:
- Blepharitis
- Hordeolum
- Dacryocystitis
- Surrounding skin disruptions:
- Insect bites
- Minor trauma
- Impetigo or other dermatologic disorders
Orbital Cellulitis
- Inflammatory process in the structures deep to the orbital septum
- Typically occurs secondary to extension from an adjacent structure:
- Sinusitis:
- Most commonly ethmoiditis penetrating through the thin lamina papyracea
- Dental abscess
- Retained foreign body in the orbit
- Puncture wounds
- Orbital fracture
- Postoperative infection
- Hematogenous spread
- Rare cause - direct extension of periorbital cellulitis
Etiology
Orbital Cellulitis
- Currently streptococcal and staphylococcal infections are the most common causes:
- S. pneumoniae, Streptococcus viridans, S. pyogenes, Streptococcus anginosus, S. aureus
- Anaerobes, bacteroides, and gram-negatives may also be seen
- All forms of orbital cellulitis carry a risk of severe morbidity and possible mortality and are therefore a true emergency:
- Permanent visual loss may occur
- May extend to subperiosteal space with abscess formation
- Cavernous sinus thrombosis and CNS infections may be life threatening
- Fungal infections are an uncommon, but an even more lethal form particularly in the immunocompromised:
- Cerebrorhino-orbital phycomycosis (CROP)
- Rapidly fatal in 75% of cases:
- 80% of cases occur in patients with a recent episode of diabetic ketoacidosis
- Predisposing factor: Severe metabolic acidosis and immunocompromise
- Begins in the paranasal sinuses and proliferates in the blood vessels causing thrombosis and necrosis
- Bloody nasal discharge is common
- May present with evidence of necrosis of the palate and /or nasal mucosa
Pediatric Considerations |
- Routine vaccination including H. influenzae and Pneumococcus have dramatically decreased periorbital and orbital cellulitis, but infections may still occur with these organisms particularly in younger children and those without at least 2 H. influenzae vaccines
- Periorbital cellulitis is overall 5 times more common and typically occurs in children <5 yr old whereas orbital cellulitis is more common in children >5 yr old
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Signs and Symptoms
Periorbital/Orbital Cellulitis
- Both present with a unilateral, red, swollen eye:
- Lid swelling may be profound
- Conjunctival injection
- Differences include:
- Source of inciting infection
- Single vs. both lids involved
- Extraocular movements (EOM) and visual acuity
- Toxicity, systemic, and neurologic symptoms
History
- Preceded by sinusitis in 60-90%, dental infection, trauma, puncture wound, or recent operation
- Swelling and redness surrounding eye in addition to eye pain, visual impairment, loss of color vision, restricted eye movements
- Headache, meningismus, and symptoms of systemic illness may be present
- Identify complicating medical problems:
Physical Exam
- Toxic appearance:
- Restricted, painful EOM
- Afferent pupillary defect
- Chemosis
- Decreased visual acuity
- Diplopia
- Proptosis
- Meningismus and neurologic findings may be seen
History
- Preceded by local skin injury, insect bite, URTI, or superficial ocular infection
- Ask about vaccination status in young children
- Low-grade fever
- Subacute presentation
Physical Exam
- Often single-lid involvement but can involve both
- Low-grade fever common:
- Normal visual acuity
- No symptoms of deep ocular involvement
Essential Workup
- Complete eye exam:
- External exam
- Visual acuity
- EOM
- Pupillary exam
- Fundoscopic exam
- Intraocular pressure measurement
- Complete neurologic exam
Diagnostic Tests & Interpretation
Lab
Supportive but not diagnostic:
- CBC:
- WBC <15,000 for periorbital cellulitis
- WBC >15,000 may suggest bacteremic periorbital or orbital cellulitis
- Blood culture
- Gram stain and culture of tissue aspirate or swab of draining purulent material:
- Chocolate agar plate when gonorrhea is suspected
Imaging
Ocular US may help identify patients who will benefit from further imaging
CT scan orbits with contrast:
- Indicated if:
- CNS or systemic signs
- Visual disturbances
- Proptosis
- Ophthalmoplegia; restricted or painful EOM
- Bilateral eyelid edema
- No improvement or deterioration after 24 hr
- Demonstrates extent of:
- Orbital cellulitis
- Sinusitis
- Orbital emphysema
- Subperiosteal abscess
- Presence of foreign body
- Cavernous sinus thrombosis
Diagnostic Procedures/Surgery
Lumbar puncture:
- Rule out CNS involvement in patients who appear toxic or manifest meningismus
- Surgery:
- Evacuate abscess
- Relieve sinusitis
- Decompress optic nerve
Differential Diagnosis
- Allergic reaction
- Dacryoadenitis
- Dacryocystitis
- Graves disease
- Hordeolum
- Inflammatory orbital pseudotumor
- Insect bite
- Orbital rhabdomyosarcoma
- Periorbital ecchymosis
- Retrobulbar hemorrhage
Initial Stabilization/Therapy
IV fluids for vomiting, dehydration, toxic appearance; assess clinical need for parenteral antibiotics
ED Treatment/Procedures
- Antipyretics
- Pain medication as needed
- Antibiotics
Periorbital Cellulitis
- Typically responds to oral antibiotics unless patient appears bacteremic or toxic:
- Augmentin: 500 mg (peds: 40 mg/kg/24 hr) PO t.i.d
- Clindamycin: 300 mg (peds: 20 mg/kg/24 hr) PO q.i.d
- Cephalexin: 500 mg (peds: 100 mg/kg/24 hr) PO q.i.d
- Bactrim: One double-strength tab (peds: 8-12 mg/kg/24 hr) PO b.i.d
- Parenteral antibiotics:
- Cefuroxime: 1-2 g (peds: 150 mg/kg/24 hr) IV q6-8h
- Clindamycin: 600 mg (peds: 40 mg/kg/24 hr) IV q.i.d
Orbital Cellulitis
- Early administration of parenteral antibiotics
- Ophthalmologic and /or ENT consultation
- If sinusitis is the source, consider decongestants
- Vancomycin 15-20 mg/kg IV q8-12h (peds: 40-60 mg/kg IV per day in 3 or 4 div doses) plus one of the following:
- Ceftriaxone 2 g IV every 24 hr (peds: 50 mg/kg per dose IV once or twice per day)
- Cefotaxime 2 g IV q4h (peds: 150-200 mg/kg IV per day in 3 doses) adults
- Ampicillin-sulbactam 3 g IV q6h (peds: 300 mg/kg IV per day in 4 div doses)
- Piperacillin-tazobactam 4.5 g IV q6h (peds: 240 mg/kg per day in 3 div doses)
- If Bacteroides is suspected organism:
- Emergent surgical intervention
- Vancomycin
- Tetanus toxoid when appropriate
- If proptosis leaves the cornea exposed:
- Lubricating drops (Lacri-Lube: 2 drops q2-4h p.r.n)
- If you suspect CROP:
- Amphotericin B IV at highest tolerated dose
- Topical amphotericin B (1 mg/mL) irrigation or nasal packing
- Local debridement
Disposition
Periorbital Cellulitis
Discharge with oral antibiotics and prompt follow-up unless:
- Evidence of systemic toxicity or presence of neurologic, visual or orbital findings
- Unable to tolerate PO antibiotics
- Progression of infection despite PO antibiotics
- Unable to arrange follow up within 24-48 hr
- High-risk H. influenzae type B
- Severe comorbidities
Orbital Cellulitis
Admit for:
- IV antibiotics
- Observation for progression
- Specialist consultation
- Surgical incision and drainage
- HauserA, FogarasiS. Periorbital and orbital cellulitis . Pediatr Rev. 2010;31:242-249.
- KangTL, SeifD, ChilstromM, et al. Ocular ultrasound identifies early orbital cellulitis . West J Emerg Med. 2014;15:394.
- PotterNJ, BrownCL, McNabAA. Orbital cellulitis: Medical and surgical management . J Clinic Experiment Ophthalmol. 2011;S:2.
- RudloeTF, HarperMB, PrabhuSP, et al. Acute periorbital infections: Who needs emergent imaging ? Pediatrics. 2010;125(4):e719-e726.
- SeltzLB, SmithJ, DurairajVD, et al. Microbiology and antibiotic management of orbital cellulitis . Pediatrics. 2011;127:e566-e572.
- UpileNS, MunirN, LeongSC, et al. Who should manage acute periorbital cellulitis in children ? Int J Pediatr Otorhinolaryngol. 2012;76:1073-1077.
- WaldE. Periorbital and orbital infections . Infect Dis Clin North Am. 2007;21(2):392-408.
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