Basics
Description
Periorbital Cellulitis
- 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 from a remote source due to valveless orbital veins
- Rare cause " ”direct extension of periorbital cellulitis
Etiology
Periorbital Cellulitis
- Streptococcus pneumoniae
- Staphylococcus aureus
- Streptococcus pyogenes
- Moraxella catarrhalis
- Haemophilus influenzae
- Gonococcus " “ rare
- Consider nonbacterial cause
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
- Routine vaccinations including Hib 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 Hib vaccines
- Periorbital cellulitis is overall 5 times more common and typically occurs in children <5 yr whereas orbital cellulitis is more common in children over 5 yr
Diagnosis
Signs and Symptoms
Periorbital Cellulitis/Orbital Cellulitis
- Both present with a unilateral, red, swollen eye:
- Lid swelling may be profound in both
- Differences include:
- Source of inciting infection
- Single vs. both lids involved
- Toxicity, systemic and neurologic symptoms
Orbital CelluLItis
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 occur
- Identify complicating medical problems:
Physical Exam
- Toxic appearance:
- Restricted, painful extraocular movements (EOM)
- Afferent pupillary defect
- Conjunctival injection
- Chemosis
- Decreased visual acuity
- Diplopia
- Proptosis
- Meningismus and neurologic findings may be seen.
Periorbital Cellulitis
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
- Red, swollen eyelid
- Often single lid involvement but can involve both
- Conjunctival injection common
- 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
Diagnosis Tests & Interpretation
Lab
Supportive but not diagnostic: ‚
- CBC:
- WBC <15,000 for periorbital cellulitis
- WBC >15,000 may suggest bacteremic periorbital cellulitis or orbital cellulitis
- Blood culture
- Gram stain and culture of tissue aspirate or swab of draining purulent material:
- Chocolate agar plate when gonorrhea suspected
Imaging
CT scan orbits with contrast: ‚
- Indicated if:
- CNS or systemic signs
- Visual disturbances
- Proptosis; restricted or painful EOM
- Ophthalmoplegia
- Bilateral edema
- No improvement or deterioration at 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 rhabdosarcoma
- Periorbital ecchymosis
- Retrobulbar hemorrhage
Treatment
Initial Stabilization/Therapy
IV fluids for vomiting, dehydration, toxic appearance, clinical need for parenteral antibiotics ‚
Ed Treatment/Procedures
- Antipyretics
- Pain medication as needed
- Antibiotics
Periorbital Cellulitis
- Typically responds to oral antibiotics unless appears bacteremic or toxic:
- Augmentin: 500 mg (peds: 45 mg/kg/24 h) PO TID
- Cephalexin: 500 mg (peds: 100 mg/kg/24 h) PO QID
- Clindamycin: 300 mg (peds: 20 mg/kg/24 h) PO QID
- Dicloxacillin: 500 mg (peds: 100 mg/kg/24 h) PO QID
- Parenteral antibiotics:
- Cefotaxime: 1 " “2 g (peds: 150 mg/kg/24 h) IV q6 " “8h
- Clindamycin: 600 mg (peds: 40 mg/kg/24 h) IV q6h
Orbital Cellulitis
- Early administration of parenteral antibiotics
- Ophthalmologic consultation for any intraocular manifestations
- If sinusitis is the source, consider ENT consultation, and add decongestants to the treatment
- Emergent surgical intervention may be necessary:
- If Bacteroides is suspected organism:
- Surgical debridement
- Vancomycin
- Tetanus toxoid when appropriate
- If proptosis leaves the cornea exposed:
- Lubricating drops (Lacri-Lube: 2 drops q2 " “4h PRN)
- If you suspect CROP:
- Amphotericin B IV at highest tolerated dose
- Topical amphotericin B (1 mg/mL) irrigation or nasal packing
- Local debridement
Medication
First Line
- Ceftriaxone: 1 " “2 g (peds: 100 mg/kg/24 h) IV q12 " “24h
- Erythromycin ophthalmologic ointment: Applied q4h to lower cul-de-sac
Second Line
Depending on suspected organism: ‚
- Gentamicin: 5 mg/kg/24 h IV
- Metronidazole: 15 mg/kg IV load, then 7.5 mg/kg q6h
- Nafcillin: 1 " “2 g (peds: 100 mg/kg/24 h) IV q4h
- Vancomycin: 1 g (peds: 40 mg/kg/24 h) q12h
Follow-Up
Disposition
Periorbital Cellulitis
Discharge with oral antibiotics and prompt follow-up unless: ‚
- Evidence of systemic toxicity, neurologic, visual or orbital findings
- Unable to tolerate PO antibiotics
- Progression of infection on oral antibiotics
- Unable to arrange follow up within 24 " “48 hr
- High-risk H. influenzae type B
- Complicating medical problems
Orbital Cellulitis
Admit for: ‚
- IV antibiotics
- Observation for progression
- Specialist consultation
- Surgical incision and drainage
Pearls and Pitfalls
- Anytime a patient presents with a red swollen eye, consider the possibility of orbital cellulitis
- Take a careful history for:
- Recent sinusitis
- Recent puncture, history of trauma or surgical procedure
- Recent dental infection " ”particularly a canine space abscess
- History of immunocompromise or recent or current episode of DKA
- Determine vaccination status in children
- Pay careful attention to exclude:
- Systemic toxicity
- Eye pain or visual impairment
- Restriction of eye movements
- Signs and symptoms of neurologic involvement
Additional Reading
- Hauser ‚ A, Fogarasi ‚ S. Periorbital and orbital cellulitis. Pediatr Rev. 2010;31:242 " “249.
- Potter ‚ NJ, Brown ‚ CL, McNab ‚ AA, Orbital cellulitis: Medical and surgical management. J Clinic Experiment Ophthalmol. 2011;S:2.
- Rudloe ‚ TF, Harper ‚ MB, Prabhu ‚ SP, et al. Acute periorbital infections: Who needs emergent imaging? Pediatrics. 2010;125(4):e719 " “e726.
- Upile ‚ NS, Munir ‚ N, Leong ‚ SC, et al. Who should manage acute periorbital cellulitis in children? Int J Pediatr Otorhinolaryngol. 2012;76:1073 " “1077.
- Wald ‚ E. Periorbital and orbital infections. Infect Dis Clin North Am. 2007;21(2):392 " “408.
See Also (Topic, Algorithm, Electronic Media Element)
- Dacryoadenitis
- Dacryocystitis
- Hyperthyroidism
- Hordeolum and Chalazion
- Pseudotumor Cerebri
Codes
ICD9
- 373.13 Abscess of eyelid
- 682.0 Cellulitis and abscess of face
ICD10
- H05.012 Cellulitis of left orbit
- H05.019 Cellulitis of unspecified orbit
- H00.039 Abscess of eyelid unspecified eye, unspecified eyelid
- H05.011 Cellulitis of right orbit
- H00.031 Abscess of right upper eyelid
- H00.032 Abscess of right lower eyelid
- H00.033 Abscess of eyelid right eye, unspecified eyelid
- H00.034 Abscess of left upper eyelid
- H00.035 Abscess of left lower eyelid
- H00.036 Abscess of eyelid left eye, unspecified eyelid
- H00.03 Abscess of eyelid
- H05.013 Cellulitis of bilateral orbits
- H05.01 Cellulitis of orbit
SNOMED
- 109245003 Cellulitis of periorbital region
- 194005002 orbital cellulitis (disorder)