Red eye, pain, blurred vision, double vision, eyelid and/or periorbital swelling, nasal congestion/discharge, sinus headache/pressure/congestion, tooth pain, infra- and/or supraorbital pain, or hypesthesia.

(See Figures 7.3.1.1 and 7.3.1.2.)

See 7.1, ORBITAL DISEASE.

• Direct extension from a paranasal sinus infection (especially ethmoiditis), focal periorbital infection (e.g., infected hordeolum, dacryoadenitis, dacryocystitis, and panophthalmitis), or dental infection.
• Sequela of orbital trauma (e.g., orbital fracture, penetrating trauma, and retained intraorbital foreign body).
• Sequela of eyelid, orbital, or paranasal sinus surgery.
• Sequela of other ocular surgery or intraocular infection (e.g., panophthalmitis) (less common).
• Vascular extension (e.g., seeding from a systemic bacteremia or locally from facial cellulitis via venous anastomoses).
• Extension from a septic cavernous sinus thrombosis.

NOTE:

In cases of unsuspected retained foreign body, cellulitis may develop months after injury (see 3.12, INTRAORBITAL FOREIGN BODY).

Organisms

• Adult: Staphylococcus species, Streptococcus species, and Bacteroides species.
• Children: Haemophilus influenzae (rare in vaccinated children).
• Following trauma: Gram-negative rods.
• Dental abscess: Mixed, aggressive aerobes and anaerobes.
• Immunocompromised patients (diabetes, chemotherapy, and HIV infection): Fungi including those that produce zygomycosis infections (e.g., Mucor) and Aspergillus.

Workup

See 7.1, ORBITAL DISEASE, for a nonspecific orbital workup.

1. History: Trauma or surgery? Ear, nose, throat, or systemic infection? Tooth pain or recent dental abscess? Stiff neck or mental status changes? Diabetes or an immunosuppressive illness? Use of immunosuppressive agents?
2. Complete ophthalmic examination to evaluate for orbital signs including afferent pupillary defect, restriction or pain with ocular motility, proptosis, increased resistance to retropulsion, elevated IOP, decreased color vision, decreased skin sensation, or an optic nerve or fundus abnormality.
3. Check vital signs, mental status, and neck flexibility. Check for preauricular or cervical lymphadenopathy. Evaluate nasal passages for signs of eschar/fungal involvement in diabetic, acidotic, or immunocompromised patients.
4. Imaging: CT scan of the orbits and paranasal sinuses (axial, coronal, and parasagittal views, with contrast if possible) to confirm the diagnosis and to rule out a retained foreign body, orbital or SPA, paranasal sinus disease, cavernous sinus thrombosis, or intracranial extension.
5. Laboratory studies: CBC with differential and blood cultures.
6. Explore and debride any penetrating wound, if present, and obtain a Gram stain and culture of any drainage (e.g., blood and chocolate agars, Sabouraud dextrose agar, and thioglycolate broth). Obtain CT before wound exploration to rule out skull base foreign body.
7. Consult neurosurgery for suspected meningitis for management and possible lumbar puncture. If paranasal sinusitis is present, consider a consultation with otorhinolaryngology for possible surgical drainage. Consider an infectious disease consultation in atypical, severe, or unresponsive cases. If a dental source is suspected, oral maxillofacial surgery should be consulted urgently for assessment, since infections from this area tend to be aggressive, potentially vision threatening, and may spread into the cavernous sinus.

NOTE:

Zygomycosis is an orbital, nasal, and sinus disease occurring in diabetic or otherwise immunocompromised patients. Typically associated with severe pain and external ophthalmoplegia. Profound visual loss may rapidly occur. Metabolic acidosis may be present. Sino-orbital zygomycosis is rapidly progressive and life threatening. See 10.10, CAVERNOUS SINUS AND ASSOCIATED SYNDROMES (MULTIPLE OCULAR MOTOR NERVE PALSIES).

1. Admit the patient to the hospital and consider consult with an infectious disease specialist and otorhinolaryngologist.
2. Broad-spectrum intravenous antibiotics to cover Gram-positive, Gram-negative, and anaerobic organisms are recommended for 48 to 72 hours, followed by oral medication for at least 1 week. The specific antibiotic agents vary.
   • In patients from the community with no recent history of hospitalization, nursing home stay, or institutional stay, we currently recommend ampicillin–sulbactam 3 g i.v. q6h for adults; 300 mg/kg per day in four divided doses for children, a maximum daily dose of 12 g ampicillin–sulbactam (8 g ampicillin component);
   • or
   • piperacillin–tazobactam 4.5 g i.v. q8h or 3.375 g q6h for adults; 240 mg of piperacillin component/kg/day in three divided doses for children, and a maximum daily dose of 18 g piperacillin.
   • In patients suspected of harboring hospital-associated methicillin-resistant Staphylococcus aureus (HA-MRSA) or in those with suspected meningitis, add concurrent intravenous vancomycin at 15 to 20 mg/kg q8–12h for adults with normal renal function and 40 to 60 mg/kg/d in three or four divided doses for children, with a maximum daily dose of 2 g. For adults who are allergic to penicillin but can tolerate cephalosporins, use vancomycin as dosed above plus: Ceftriaxone 2 g i.v. daily and metronidazole 500 mg i.v. q8h (not to exceed 4 g/d).
   • For adults who are allergic to penicillin/cephalosporin, treat with a combination of a fluoroquinolone (for patients >17 years of age, moxifloxacin 400 mg i.v. daily or ciprofloxacin 400 mg i.v. q12h or levofloxacin 750 mg i.v. daily) and metronidazole 500 mg i.v. q8h.

NOTE:

Antibiotic dosages may need to be reduced in the presence of renal insufficiency or failure. Peak and trough levels of vancomycin are usually monitored, and dosages are adjusted as needed. BUN and creatinine levels are monitored closely. Also, be aware that many antibiotics (especially tetracycline derivatives) may change the efficacy of warfarin and other anticoagulants. It is prudent to obtain internal medicine consultation for the management of anticoagulants while the patient is using antibiotics.

NOTE:

The incidence of community-acquired methicillin-resistant S. aureus (CA-MRSA) is increasing in the United States, especially in urban areas. It is extremely difficult to clinically distinguish CA-MRSA from more conventional microbial pathogens. CA-MRSA may progress more rapidly and present with greater clinical severity than typical bacterial pathogens, but these are subjective criteria. It is prudent to cover CA-MRSA in severe cases of orbital cellulitis, in cases with a suspected skin source, in cases that have failed conventional therapy, or in areas of high CA-MRSA incidence. CA-MRSA is typically treated with tetracycline or a tetracycline derivative, trimethoprim/sulfamethoxazole, or clindamycin, although clindamycin resistance is on the rise.

• Nasal decongestant spray as needed for up to 3 days. Nasal corticosteroid spray may also be added to quicken the resolution of sinusitis.
• Erythromycin or bacitracin ointment q.i.d. for corneal exposure and chemosis if needed.
• If the orbit is tight, an optic neuropathy is present, or the IOP is severely elevated, immediate canthotomy/cantholysis may be needed. See 3.10, TRAUMATIC RETROBULBAR HEMORRHAGE for indications and technique.
• The use of systemic corticosteroids in the management of orbital cellulitis remains controversial. If systemic corticosteroids are considered, it is probably safest to wait 24 to 48 hours until an adequate intravenous antibiotic load has been given (three to four doses). Studies of pediatric orbital cellulitis with or without abscess found that the concomitant use of systemic corticosteroids with antibiotics shortened the length of intravenous antibiotic therapy and hospital stay.

Re-evaluate at least twice daily in the hospital for the first 48 hours. Severe infections may require multiple daily examinations. Clinical improvement may take 24 to 36 hours.

1. Progress is monitored by:
   • Patient’s symptoms.
   • Temperature and white blood cell (WBC) count.
   • Visual acuity and evaluation of optic nerve function.
   • Extraocular motility.
   • Degree of proptosis and any displacement of the globe (significant displacement may indicate an abscess).
   • C-reactive protein (CRP) has been found to be a helpful clinical marker in some studies. One study suggested initiating oral corticosteroids with antibiotic therapy at a threshold CRP of ≤4 mg/dL.
2. Evaluate the cornea for signs of exposure.
3. Check IOP.
4. Examine the retina and optic nerve for signs of posterior compression (e.g., chorioretinal folds), inflammation, or exudative retinal detachment.
5. If orbital cellulitis is clearly and consistently improving, then the regimen can be changed to oral antibiotics (depending on the culture and sensitivity results) to complete a 10- to 14-day course. We often use:
   • Amoxicillin/clavulanate: 25 to 45 mg/kg/d p.o. in two divided doses for children and a maximum daily dose of 90 mg/kg/d; 875 mg p.o. q12h for adults;
   • or
   • Cefpodoxime: 10 mg/kg/d p.o. in two divided doses for children and a maximum daily dose of 400 mg; 200 mg p.o. q12h for adults;
   • or
   • If CA-MRSA is suspected, recommended oral treatment regimens include doxycycline 100 mg p.o. q12h (not in pregnant or nursing women and not in children younger than 8 years), one to two tablets trimethoprim/sulfamethoxazole 160/800 mg p.o. q12h, clindamycin 450 mg p.o. q6h, or linezolid 600 mg p.o. b.i.d. (only with approval from an infectious disease specialist, given current low resistance).
   • The patient is examined every few days as an outpatient until the condition resolves and instructed to return immediately with worsening signs or symptoms.

NOTE:

If clinical deterioration is noted after an adequate antibiotic load (three to four doses), a CT scan of the orbit and brain with contrast should be repeated to look for abscess formation (see 7.3.2, SUBPERIOSTEAL ABSCESS). If an abscess is found, surgical drainage may be required. Because radiographic findings may lag behind the clinical examination, clinical deterioration may be the only indication for surgical drainage. Other conditions that should be considered when the patient is not improving include cavernous sinus thrombosis, meningitis, resistant organism (HA-MRSA, CA-MRSA), aggressive organism (often from an undiagnosed odontogenic source), or a noninfectious etiology.

NOTE:

Medication noncompliance is an extremely common reason for recurrence or failure to improve. The oral antibiotic regimen should be individualized for ease of use and affordability. Effective generic alternatives to brand name antibiotics include doxycycline and trimethoprim/sulfamethoxazole.