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other; reduced red color may indicate optic nerve involvement.

Confrontation visual field testing

DIFFERENTIALDIAGNOSIS

Preseptal cellulitis

– Eyelid erythema with or without conjunctival erythema, afebrile, no pain on eye movement, no diplopia, normal eye exam, vision intact

Metastatic tumors and autoimmune inflammation may masquerade as orbital cellulitis in rare cases; usually present with painless slow onset of symptoms Idiopathic orbital inflammatory disease (orbital pseudotumor) (1)[C]

–Afebrile, normal WBCs; usually subacute, may have pain, responds to steroids after ruling out orbital cellulitis

Orbital foreign body

Arteriovenous fistula (carotid-cavernous fistula)

– Spontaneous or due to trauma; bruit may be present; insidious, subacute onset

Cavernous sinus thrombosis

–Signs of orbital cellulitis with cranial nerves III, IV, V, and VI findings; often bilateral and acute

–Severely ill

Acute thyroid orbitopathy

–Afebrile; possible signs of thyroid disease

–Bilateral orbital involvement

Orbital tumor

–Rhabdomyosarcoma, acute lymphoblastic leukemia, or metastatic tumors

–Unilateral

–Slow onset

Trauma, insect bite, ruptured dermoid cyst

Clinical signs help distinguish preseptal from orbital cellulitis. Preseptal infection causes erythema, induration, and tenderness of the eyelid and/or periorbital tissues, and patients rarely show signs of systemic illness. Local skin trauma, lacerations, or bug bites can be seen. Extraocular movements and visual acuity are intact.

Orbital cellulitis also presents with complaints of a red, swollen, painful eye or eyelid. It also results in proptosis, conjunctival edema, ophthalmoplegia (diminished ocular movement), or decreased visual acuity.

DIAGNOSTIC TESTS & INTERPRETATION

CBC with differential, C-reactive protein, ESR

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Swab cultures of eye secretions or nasopharyngeal aspirates are often contaminated by normal flora but may identify causative organism(s).

Cultures from orbital and sinus abscesses at the time of surgery more often yield positive results but should be limited to cases where invasive procedures are indicated. Cultures from sinus aspirates and abscesses may grow multiple organisms.

Blood cultures (usually negative) should be obtained prior to initiation of antibiotic therapy in ill-appearing or febrile patients.

Initial Tests (lab, imaging)

CT scan of orbits and sinuses with axial and coronal views, with and without contrast, is imaging modality of choice (4)[C]. US and MRI are alternatives.

–Thin section (2 mm) CT, coronal and axial views with bone windows to differentiate preseptal from orbital cellulitis, confirm extension into orbit, detect coexisting sinus disease, identify orbital or subperiosteal abscesses requiring surgery

–Deviation of medial rectus indicates intraorbital involvement.

MRI offers superior soft tissue resolution for identification of cavernous sinus thrombosis but is less effective for bone imaging.

US is used to rule out orbital myositis, locate FBs or abscesses, and follow progression of drained abscess.

Follow-Up Tests & Special Considerations

Frequent eye exam and vital signs (q4h)

Identify associated conditions, such as meningitis or orbital abscess.

Diagnostic Procedures/Other

Consult ophthalmology for slit lamp and dilated funduscopic exam; proptosis, color vision, automated visual field; and need for surgery.

TREATMENT

Admit patients with orbital cellulitis for monitoring and treatment with broadspectrum IV antibiotics (1).

MEDICATION

Empiric antibiotic therapy to cover pathogens associated with acute sinusitis (S. pneumoniae, H. influenzae, M. catarrhalis, Streptococcus pyogenes) as

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well as for S. aureus, S. anginosus, and anaerobes

Modify IV antibiotic treatment when culture and sensitivity results are available. Duration of IV therapy is usually a week. Additional PO therapy depends on response.

PO antibiotic therapy for 2 to 3 weeks or longer (3 to 6 weeks) is recommended for patients with severe sinusitis and bony destruction.

First Line

Ampicillin/sulbactam (Unasyn) or ceftriaxone plus metronidazole or clindamycin if anaerobic infection is suspected (3)

–Ampicillin/sulbactam: 3 g IV q6h for adult; 200 to 300 mg/kg/day divided q6h for children

–Ceftriaxone: 1 to 2 g IV q12h for adults or 100 mg/kg/day divided BID in children with maximum 4 g/day

–Clindamycin: 600 mg IV q8h for adults; 20 to 40 mg/kg/day IV q6–8h for children (5)

–Metronidazole: 500 mg IV q8h for adult; 30 to 35 mg/kg/day divided q8h for children

ALERT

In severe orbital cellulitis and in suspected, or culture-proven MRSAinfection, vancomycin remains the parenteral drug of choice. Use in conjunction with agents to cover gram-negative bacteria.

Vancomycin: 1 g IV q12h for adults; 40 mg/kg/day IV divided q8–12h, max daily dose 2 g for children (3)

ADDITIONALTHERAPIES

Steroid use is controversial (1)[C].

PO steroids as an adjunct to IV antibiotics for orbital cellulitis may speed resolution of inflammation (6)[C].

Topical erythromycin or nonmedicated ophthalmic ointment protects the cornea from exposure in cases with severe proptosis.

PO antibiotics for ≥2 weeks are traditionally recommended following IV treatment.

Children may be treated with amoxicillin/clavulanate 20 to 40 mg/kg/day divided TID or in adults 250 to 500 mg TID.

ISSUES FOR REFERRAL

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Always admit to the hospital and consult with ophthalmology. Consider consultation with ID and ENT for orbital cellulitis; neurology/neurosurgery if intracranial spread is suspected

SURGERY/OTHER PROCEDURES

IV antibiotic therapy is the initial therapy.

Surgical intervention warranted for visual loss, complete ophthalmoplegia, well-defined large abscess (>10 mm) on presentation or no clinical improvement after 24 to 48 hours of antibiotic therapy

Trauma cases may need débridement or FB removal.

Orbital abscess may need surgical drainage.

Surgical drainage with 4 to 8 weeks of antibiotics is the treatment of choice for brain abscess.

Surgical interventions may include external ethmoidectomy, endoscopic ethmoidectomy, uncinectomy, antrostomy, and subperiosteal drainage.

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

Patients with orbital cellulitis should be admitted for IV antibiotics and serial eye exams to evaluate progression of infection or involvement of optic nerve.

Follow temperature, WBC, visual acuity, pupillary reflex, ocular motility, and proptosis.

Repeat CT scan, or surgical intervention, may be required for worsening orbital cellulitis cases.

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

Patient Monitoring

Serial visual acuity testing and slit lamp exams

ALERT

Bedside exam q4h is indicated, as complications can develop rapidly.

PATIENT EDUCATION

Maintain proper hand washing and good skin hygiene.

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Avoid skin or lid trauma.

COMPLICATIONS

Vision loss, CNS involvement, and death

Permanent vision loss

–Corneal exposure

–Optic neuritis

–Endophthalmitis

–Septic uveitis or retinitis

–Exudative retinal detachment

–Retinal artery or vein occlusions

–Globe rupture

–Orbital compartment syndrome

CNS complications

– Intracranial abscess, meningitis, cavernous sinus thrombosis (2)[B]

REFERENCES

1.Chadha NK. An evidence-based staging system for orbital infections from acute rhinosinusitis. Laryngoscope. 2012;122(Suppl 4):S95–S96.

2.Hauser A, Fogarasi S. Periorbital and orbital cellulitis. Pediatr Rev. 2010;31(6):242–249.

3.Seltz LB, Smith J, Durairaj VD, et al. Microbiology and antibiotic management of orbital cellulitis. Pediatrics. 2011;127(3):e566–e572.

4.Mahalingam-Dhingra A, Lander L, Preciado DA, et al. Orbital and periorbital infections: a national perspective. Arch Otolaryngol Head Neck Surg. 2011;137(8):769–773.

5.Bedwell J, Bauman NM. Management of pediatric orbital cellulitis and abscess. Curr Opin Otolaryngol Head Neck Surg. 2011;19(6):467–473.

6.Pushker N, Tejwani LK, Bajaj MS, et al. Role of oral corticosteroids in orbital cellulitis. Am J Ophthalmol. 2013;156(1):178.e1–183.e1.

CODES

ICD10

H05.019 Cellulitis of unspecified orbit

H05.011 Cellulitis of right orbit

H05.012 Cellulitis of left orbit

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CLINICALPEARLS

Most orbital cellulitis cases result from sinusitis.

MRSAorbital cellulitis may present without an associated upper respiratory infection.

CT of orbits and sinuses with axial and coronal views with and without contrast is diagnostic modality of choice for suspected cases of orbital cellulitis.

Patients with orbital cellulitis must be admitted to the hospital for visual monitoring and IV antibiotic therapy.

Older age (>10 years) and diplopia predict need for surgical intervention in children.

Ophthalmoplegia, mental status changes, contralateral cranial nerve palsy, or bilateral orbital cellulitis raise suspicion for intracranial involvement.

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CELLULITIS, PERIORBITAL

Fozia Akhtar Ali, MD

BASICS

DESCRIPTION

An acute bacterial infection of the skin and subcutaneous tissue anterior to the orbital septum; does not involve the orbital structures (globe, fat, and ocular muscles)

Synonym(s): preseptal cellulitis

ALERT

It is essential to distinguish periorbital cellulitis from orbital cellulitis. Orbital cellulitis is a potentially life-threatening condition. Orbital cellulitis is posterior to the orbital septum; symptoms include restricted eye movement, pain with eye movement, proptosis, and vision changes.

EPIDEMIOLOGY

Occurs more commonly in children; mean age 21 months

3 times more common than orbital cellulitis (1)[C]

Incidence

Increased incidence in the winter months (due to increased cases of sinusitis) (1) [C]

ETIOLOGYAND PATHOPHYSIOLOGY

The anatomy of the eyelid distinguishes periorbital (preseptal) from orbital cellulitis:

–Aconnective tissue sheet (orbital septum) extends from the orbital bones to the margins of the upper and lower eyelids; it acts as a barrier to infection of deeper orbital structures.

–Infection of tissues anterior to the orbital septum is periorbital (preseptal) cellulitis.

–Infection deep to the orbital septum is orbital (postseptal) cellulitis.

Periorbital cellulitis typically arises from a contiguous infection of soft tissues of the face.

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–Sinusitis (via lamina papyracea) extension

–Local trauma; insect or animal bites

–Foreign bodies

–Dental abscess extension

–Hematogenous seeding

Common organisms (1)[C]

–Staphylococcus aureus, typically MSSA(MRSAis increasing)

–Staphylococcus epidermidis

–Streptococcus pyogenes

Atypical organisms

–Acinetobacter sp.; Nocardia brasiliensis

–Bacillus anthracis; Pseudomonas aeruginosa

–Neisseria gonorrhoeae; Proteus sp.

–Pasteurella multocida; Mycobacterium tuberculosis; Trichophyton sp. (ringworm)

Since vaccine introduction, the incidence of Haemophilus influenzae disease has decrease, (should still be suspected in unimmunized or partially immunized patients).

Genetics

No known genetic predisposition

RISK FACTORS

Contiguous spread from upper respiratory infection

Acute sinusitis

Conjunctivitis

Blepharitis

Dental infection

Local skin trauma/puncture wound

Insect bite

Bacteremia

GENERALPREVENTION

Avoid dermatologic trauma around the eyes.

Avoid swimming in fresh or salt water with facial skin abrasions. Routine vaccination: particularly H. influenzae type B and Streptococcus pneumoniae

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DIAGNOSIS

HISTORY

Induration, erythema, warmth, and/or tenderness of periorbital soft tissue, usually with normal vision and normal eye movements

Chemosis (conjunctival swelling), proptosis; pain with extraocular eye movements can occur in severe cases of periorbital cellulitis and are concerning for orbital cellulitis.

Fever (not always present)

ALERT

Pain with eye movement, fever, and conjunctival swelling raise the suspicion for orbital cellulitis.

PHYSICALEXAM

Vital signs and general appearance (Patients with orbital cellulitis often appear systemically ill.)

Thorough HEENT examination

Inspect eyes and surrounding structures—lids, lashes, conjunctiva, and skin. Erythema, swelling, and tenderness of lids without orbital congestion

–Violaceous discoloration of eyelid is more commonly associated with H. influenzae.

Evaluate for any skin break down.

Look for vesicles to rule out herpetic infection.

Inspect nasal vaults and palpate sinuses for signs of acute sinusitis.

Examine oral cavity for dental abscesses.

Test ocular motility and visual acuity.

DIFFERENTIALDIAGNOSIS

Orbital cellulitis

–Orbital cellulitis may have the same signs and symptoms as periorbital cellulitis, with fever, proptosis, chemosis, ophthalmoplegia, decreased

visual acuity, pain with ocular movement. Abscess

Dacryocystitis

Hordeolum (stye)

Allergic inflammation Orbital or periorbital trauma

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Idiopathic inflammation from orbital pseudotumor

Orbital myositis

Rapidly progressive tumors

–Rhabdomyosarcoma

–Retinoblastoma

–Lymphoma

Leukemia

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

CBC with differential

Blood cultures (low yield) (2)[C]

Wound culture of purulent drainage (if present)

Imaging is indicated with suspicion for orbital cellulitis (marked eyelid swelling, fever, and leukocytosis or failure to improve on appropriate antibiotics within 24 to 48 hours).

CT to evaluate the extent of infection and detect orbital inflammation or abscess:

–The classic sign of orbital cellulitis on CT scan is bulging of the medial rectus.

–CT with contrast, thin sections (2 mm); coronal and axial views with bone windows

Follow-Up Tests & Special Considerations

Children with periorbital or orbital cellulitis often have underlying sinusitis. If a child is febrile, <15 months old, and appears toxic, admit for blood cultures, antibiotic therapy, and consider lumbar puncture.

TREATMENT

MEDICATION

Treat periorbital cellulitis with oral antibiotics and ensure close follow-up. Empiric antibiotic treatment should cover the most likely organisms (Staphylococcus and Streptococcus).

Observe local prevalence of MRSAto determine need for coverage. No evidence that IV antibiotics are more effective than PO in reducing

recovery time or preventing secondary complications in simple periorbital

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