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Cellulitis, Orbital

Basics

  • Acute severe infection posterior to orbital septum (vs preseptal cellulitis anterior to septum).
  • Vision-threatening; can cause proptosis, ophthalmoplegia, optic nerve compression.
  • Sinusitis is the main source, especially ethmoid sinus via lamina papyracea.

Epidemiology

  • More common in children and males in childhood; no gender difference in adults.
  • Incidence decreased after Haemophilus influenzae type b (Hib) vaccination.

Etiology and Pathophysiology

  • Most common pathogens: Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus anginosus.
  • Haemophilus no longer leading cause.
  • MRSA increasingly important.
  • Spread often from ethmoid sinus (thin lamina papyracea).
  • Orbital septum separates preseptal and orbital infections.
  • Infection can cause orbital apex syndrome, vision loss.

Risk Factors

  • Sinusitis (80-100% cases), pansinusitis in adults.
  • Orbital trauma, foreign body, surgery, sinus surgery.
  • Periorbital/dental infections, acute dacryocystitis/dacryoadenitis.
  • Immunosuppression increases risk.

Prevention

  • Hib vaccination.
  • Prompt treatment of sinusitis.
  • Proper wound care and perioperative monitoring.

Associated Conditions

  • Sinusitis, preseptal cellulitis, trauma, orbital foreign bodies.
  • Complications: optic neuritis, retinal detachment, meningitis, abscesses, cavernous sinus thrombosis, death.

Diagnosis

History

  • Acute red, swollen, tender eye/eyelid.
  • Painful eye movements, diplopia, proptosis.
  • Fever, malaise, stiff neck, mental changes.
  • History of sinusitis, trauma, surgery, dental infection.

Physical Exam

  • Vital signs; assess visual acuity.
  • Eyelid swelling, proptosis, conjunctival edema.
  • Pain on eye movements; ophthalmoplegia.
  • Red desaturation test for optic nerve involvement.
  • Pupillary reflex for afferent defect.
  • Confrontation visual fields.

Differential Diagnosis

  • Preseptal cellulitis (no pain on eye movement, no diplopia, no vision loss).
  • Orbital pseudotumor, tumors, carotid-cavernous fistula.
  • Cavernous sinus thrombosis, thyroid orbitopathy, trauma.

Diagnostic Tests

  • CBC, CRP, ESR (elevated in orbital cellulitis).
  • Blood cultures (usually negative but done if febrile/ill).
  • Swabs from eye/nasopharynx (often contaminated).
  • Imaging:
  • CT orbits and sinuses with contrast: gold standard to confirm orbital involvement, abscess.
  • MRI: better for soft tissue, cavernous sinus thrombosis.
  • Ultrasound: abscess localization, foreign body detection.

Treatment

General Measures

  • Admit for IV antibiotics and serial ophthalmologic exams.
  • Monitor vision, eye movements, signs of intracranial spread.

Medication

  • Empiric IV antibiotics targeting:
  • S. pneumoniae, H. influenzae, Moraxella catarrhalis
  • S. aureus (including MRSA)
  • S. anginosus, anaerobes
  • First line:
  • Vancomycin (MRSA coverage)
  • PLUS ceftriaxone, cefotaxime, ampicillin-sulbactam, or piperacillin-tazobactam
  • Metronidazole for anaerobic coverage
  • Penicillin allergy alternatives: vancomycin plus ciprofloxacin or levofloxacin
  • Oral step-down antibiotics after improvement, for 2-6 weeks depending on severity.

Additional Therapies

  • Steroids controversial; may speed resolution with IV antibiotics.
  • Nasal decongestants often recommended.
  • Ophthalmic ointments to protect cornea if proptosis severe.

Surgery

  • Required if vision loss, ophthalmoplegia, large abscess (>10 mm), or no improvement after 24-48h antibiotics.
  • Drain abscesses and address complications.

Admission

  • Hospital admission mandatory.
  • Frequent eye exams (q4h bedside) due to rapid progression risk.

Ongoing Care and Follow-up

  • Monitor visual acuity, pupillary reflex, extraocular movements.
  • Repeat imaging if clinical deterioration.

Patient Education

  • Emphasize hygiene and avoidance of periocular trauma.
  • Early treatment of sinusitis.

Prognosis

  • Pre-antibiotic blindness and death rates high (20% and 17% respectively).
  • Current vision loss rates 3-11%.
  • Prompt treatment decreases morbidity and mortality.

Complications

  • Vision loss, permanent blindness.
  • CNS involvement: meningitis, cavernous sinus thrombosis, brain abscess.
  • Orbital abscess, subperiosteal abscess.
  • Orbital apex syndrome.

Clinical Pearls

  • Differentiate orbital from preseptal cellulitis via exam and CT.
  • Most cases arise from sinusitis.
  • Admit all orbital cellulitis cases for IV antibiotics and close monitoring.
  • Older children and diplopia predict surgical need.
  • Ophthalmoplegia, altered mental status, bilateral disease suggest intracranial spread.

References:

  1. El Mograbi A, Ritter A, Najjar E, et al. Orbital complications of rhinosinusitis in adults: analysis over 13 years. Ann Otol Rhinol Laryngol. 2019;128(6):563-568.
  2. Khan SA, Hussain A, Phelps PO. Current clinical diagnosis and management of orbital cellulitis. Expert Rev Ophthalmol. 2021;16(5):387-399.