Eye

Orbital Cellulitis

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Orbital Cellulitis, Postseptal Cellulitis

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