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A. Characteristics navigator

  1. Infection involves the superficial soft tissues
  2. Orbital septum is a continuation of periosteum of bone of orbit
    1. This allows easy extension of infection
    2. Eyelid contains no subcutaneous fat
    3. Eyelid musculofibrous tissues allows rapid accumulation of large amounts of fluid
  3. Optic Nerve Involvement May Occur
    1. Abnormal pupillary reactions (afferent pupillary defect)
    2. Loss of ocular movements
    3. Loss of visual acuity
  4. Bactermia may develop rapidly from periorbital cellulitis
  5. Predisposing Factors for Development of Bacteremia
    1. Younger age
    2. Higher temperatures
    3. White blood count (WBC) >20K/µL
    4. Violaceous color of eyelid
    5. Preceding upper respiratory infection (URI)

B. Etiologynavigator

  1. Local Trauma
    1. Laceration, abrasion, or insect bites
    2. Staphylococcus aureus
    3. Streptococcus pyogenes
  2. Zoster Virus
    1. Usually as shingles involving Cranial Nerve V
    2. Bacterial superinfection of shingles' lesions is major concern
  3. Bacteremia
    1. Streptococcus pneumoniae
    2. S. pyogenes
    3. Heamophilus influenzae (rare in children immunized with HIB vaccine)
  4. Sinusitis
    1. Reactive inflammation
    2. Edema from vascular and lymphatic congestion

C. Symptomsnavigator

  1. Unilteral periocular redness, swelling and warmth
  2. Tenderness of eyelid
  3. Fever
  4. Orbital involvement
    1. Proptosis
    2. Ophthalmoplegia
    3. Changes in visual acuity

D. Physical Examination navigator

  1. Presence and degree of proptosis
  2. Extra-ocular movements (intact or not)
  3. Visual acuity
  4. Pupillary reaction to light
  5. Chemosis (tearing)
  6. Upper eye-lid eversion

E. Laboratory Evaluationnavigator

  1. Blood cultures are critical
  2. Gram stain, culture of purulent material
  3. Tzanck preparation of leading edge tissue if varicella zoster (shingles) is suspected
  4. Conjunctival or throat swabs are not helpful
  5. Consider lumbar puncture in young febrile infants to rule out meningitis
  6. Sinus Evaluation
    1. Computerized tomographic (CT) scans preferred over usual plain radiographs
    2. Unilateral opacification
    3. Marked mucosal thickening
    4. Air fluid levels
  7. CT scans of facial area to assess orbital extension
  8. Evaluate for atypical organisms (such as fungi) in immunosuppressed patients

F. Differential Diagnosis navigator

  1. Allergies
  2. Trauma
  3. Insect bite of eyelid
  4. Tumor
  5. Nasal or zygomatic fractures
  6. Sty or hordeolum - pyogenic infection of hair follicle or sebaceous gland
  7. Dacryocystitis - infection of lacrimal gland
  8. Dacryoadenitis following viral infection such as measles
  9. Blepharitis - chronic inflammation of lid margins
  10. Adenoviral keratoconjunctivitis
  11. Herpes simplex infection

G. Treatmentnavigator

  1. Parenteral antibiotics for
    1. Child with abrupt onset of fever with eye swelling and redness
    2. Adult with evidence of optic nerve involvement
    3. Underlying immunodeficiency
  2. Initial therapy should cover major gram positive organisms
    1. Topical erythromycin ophthalmic is often used in conjunction with systemic antibiotics
    2. Consider H. influenza also
  3. Oral or parenteral acyclovir (or related drug) for herpes infections
  4. After clear improvement, appropriate oral antibiotic should be given for 7-10 days
  5. Clinical situation and sensitivities of infectious isolate should refine therapy

References navigator

  1. Malinow I and Powell KR. 1993. Pediatric Annals. 22(4):241 abstract
  2. Powell KR, Kaplan SB, Hall CB, et al. 1988. Am J Dis Childhood. 142(8):853 abstract