Eye
Orbital Cellulitis
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Orbital Cellulitis
, Postseptal Cellulitis
See Also
Preseptal Cellulitis
Red Eye
Erysipelas
Epidemiology
Mean age: 12 years old
Pathophysiology
Orbital tissue is involved in addition to the
Eyelid
infection in
Preseptal Cellulitis
findings
Infection may involve the
Muscle
, fat and connective tissue contained in the orbital compartment
Less than 10% of Orbital Cellulitis extends from
Preseptal Cellulitis
(most cases are from
Bacteria
l
Sinusitis
)
Bacteria
l
Ethmoid Sinus
itis or
Maxillary Sinus
itis extension to involve orbit (60-80% of cases)
Extends via thin medial bony wall (
Ethmoid Sinus
) or inferior wall (
Maxillary Sinus
) into orbit
Extends via retrobulbar veins (no valves) into lids
Rarely associated with frontal or
Sphenoid Sinus
itis
Typical Organisms (one third of cases are polymicrobial)
Streptococcus Pneumoniae
Streptococcus Pyogenes
(
Group A Streptococcus
)
Staphylococcus aureus
(primarily
MSSA
in studies)
Staphylococcus
intermedius
Cutibacterium acnes (Propionobacterium acnes)
Moraxella catarrhalis
Haemophilus
Influenza
e (under age 3 years, decreasing due to
Immunization
)
Mixed
Bacterial Infection
including
Anaerobe
s
Anosike (2022) J Pediatric Infect Dis Soc 11(5): 214-20 [PubMed]
Organisms in
Immunocompromised
patients (e.g.
HIV Infection
or
AIDS
)
Pseudomonas
aeruginosa
Opportunistic fungal infections
Course
Stages
Inflammatory
Edema
Orbital Cellulitis
Proptosis
Reduced ocular mobility
Subperiosteal Abscess
Frank Orbital Abscess
Signs
Starts as mild inflammatory edema
URI history
Low grade or absent fever
Slowly progressive clinical course
Swollen and discolored
Eyelid
Progresses to orbital involvement
Fever
Pain and limitation of eye
Extraocular Movement
Key distinguishing feature from
Preseptal Cellulitis
Diplopia
on side gaze due to inability to move eye
Inflamed or entrapped extraocular
Muscle
results in disconjugate gaze
Severe cases with orbital edema (pressure on globe and
Optic Nerve
)
Proptosis
(
Exophthalmos
)
Marcus Gun
Pupil
(relative afferent pupilary defect)
Swinging Flashlight Test
abnormal (affected pupil constricts less in response to light)
Retinal Exam
Venous dilatation and tortuosity
Papilledema
Chemosis
Decreased Visual Acuity
Labs
May assist to support diagnosis, but labs do NOT exclude Orbital Cellulitis
Imaging is recommended if Orbital Cellulitis is suspected, regardless of lab results
Imaging
CT Sinus
es and orbits with IV Contrast (preferred in most cases)
IV contrast is preferred
Highlights structures with increased
Blood Flow
Identifies abscess (rim enhancement)
May be performed without IV contrast if contraindicated
Non-contrast CT may demonstrate
Proptosis
, fat stranding, orbital
Muscle
thickening
Adjacent Ethmoid or
Maxillary Sinus
itis (fluid filled sinus with mucosal thickening)
Lack of
Sinusitis
on CT, makes Orbital Cellulitis diagnosis much less likely
Other imaging options
MRI sinuses and orbits with and without IV contrast
Similar efficacy to orbital CT in the diagnosis of Orbital Cellulitis
Benefits from no radiation (e.g. children), but longer, more expensive, less available study
Typically requires sedation in younger children
CT Head
Consider in suspected
Brain Abscess
CTV Head
Consider in suspected
Cavernous Sinus Thrombosis
Indications: Distinguish preseptal from Orbital Cellulitis (and evaluate sinus involvement)
Change in
Visual Acuity
Proptosis
Decreased
Extraocular Movement
s
Diplopia
Eye not able to be examined (e.g. due to local
Eyelid Edema
)
Differential Diagnosis
Preseptal Cellulitis
Orbital pseudotumor
Masses
Rhabdomyosarcoma
Neuroblastoma
Leukemia
Lymphoma
Other tumors
Neurofibroma
Glioma of the
Optic Nerve
Dermoid cyst
Lymphangioma
Hemangioma
Wilms tumor
Management
Gene
ral
Observe in hospital with at least daily
Visual Acuity
and
Pupillary Light Reflex
Repeat
CT Sinus
es/orbits if not improved in 48 hours
Antibiotic
s course: 7-14 days
Parenteral
Antibiotic
s (initial 2-3 drug regimen)
Antibiotic
1 (choose 1)
Vancomycin
15-20 mg/kg IV every 8-12 hours (preferred) OR
Daptomycin
6 mg/kg IV every 24 hours OR
Linezolid
600 mg IV every 12 hours
Antibiotic
2 (choose 1 )
Piperacillin
-Tazobactam (
Zosyn
) 4.5 g IV every 8 hours OR
Ceftriaxone
2 g IV every 24 hours AND
Metronidazole
1 g IV every 12 hours OR
Moxifloxicin 400 mg IV every 24 hours (if
Penicillin
allergic)
Oral
Antibiotic
s (once infection controlled and based on microbiology)
See
Preseptal Cellulitis
management
Also consider empiric treatment with oral
Antibiotic
s when diagnostic imaging is equivocal
Consider additional
MRSA
coverage (e.g.
Septra
, doxycyline)
Amoxicillin
-Clavulanate (
Augmentin
)
Cefuroxime
(
Ceftin
) or
Cefpodoxime
Cefprozil
(
Cefzil
)
Surgical drainage indications
Large abscess
Significant symptoms (esp. orbital edema and
Proptosis
)
Insufficient improvement on
Antibiotic
s
References
(2017) Sanford Guide, accessed on IOS 2/2/2017
Carlisle (2015) Am Fam Physician 92(2): 106-12 [PubMed]
Complications
Endophthalmitis
(risk of permanent
Vision Loss
)
Epidural Abscess
or
Subdural Abscess
Meningitis
Sepsis
Cavernous Sinus Thrombosis
or Dural sinus thrombosis
May present first with
Cranial Nerve 6 Palsy
(
Abducens Nerve Palsy
), unable to gaze laterally
Prognosis
Advanced
AIDS
Associated with poor outcomes related to
Pseudomonas
and opportunistic fungal infections
Johnson (1999) Arch Ophthalmol 117(1): 57-64 [PubMed]
References
(2023) Sanford Guide, accessed 7/1/2023
Broder (2023) Crit Dec Emerg Med 37(11): 20-2
Williams (2017) Crit Dec Emerg Med 31(2): 3-12
Givner (2002) Pediatr Infect Dis 21:1157-8 [PubMed]
Micek (2007) Clin Infect Dis 45:S184-90 [PubMed]
Tovilla-Canales (2001) Curr Opin Ophthalmol 12:335-41 [PubMed]
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