Periorbital and Orbital Cellulitis

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ANATOMY

The orbital septum is a thin membrane that separates the eyelid from the deeper orbital structures of the eye. Presptal cellulitis is infection of tissue anterior to the septum; it primarily involves the eyelids up to the eyebrows and surrounding soft tissues. Orbital cellulitis includes infection posterior to the septum

 

EVALUATION

 It is important to differentiate between the two because Orbital cellulitis is a medical emergency! Determine if there is a past history of sinus or dental disease or if there was trauma to the eye. If there is a considerable amount of swelling, it may be necessary to retract the eyelids. If retraction is not possible, consult an ophthalmologist and obtain imaging.

Differential diagnosis of eyelid swelling includes allergic reactions and edema from hypoproteinemia (usually bilateral), swelling secondary to sinus infection, fluid overload, and trauma.  Proptosis can also be due to orbital pseudotumor, thyroid disorders, orbital myositis, Wegener granulomatosis, sarcoidosis, leukemia, and retinoblastoma.

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Preseptall Cellulitis

Epidemiology: Most common in patients younger than 5. Three times more common than orbital cellulitis.  Most often associated with skin breakdown.  With immunizations, unlikely hematogenous origin.

Microbiology: Staph aureus, Staph epidermidis, and Strep pyogenes are responsible for 75% of preorbital infections.  Hematogenous spread of Haemophilius influenzae should be considered in unimmunized or partially immunized children.

Symptoms: Unilateral erythema, swelling, warmth and tenderness of eyelid. Fever and systemic signs may be present.  No proptosis, no ophthalmolplegia, normal vision

Diagnosis: Usually clinical findings are enough. If unable to inspect the eye, should get CT scan. Wound cultures or blood cultures may be necessary if resistant organism is suspected or if there are significant systemic symptoms.

Treatment: If simple infection and patient can tolerate PO, clindamycin, Augmentin, or first generation cephalosporin. If MRSA suspected, oral TMP-SMX or clindamycin.  If complicated or due to hematogenous spread, admit to hospital and give IV third generation cephalosporin plus clindamycin or vancomycin if MRSA is suspected. If there is improvement, can transition to PO meds for a total of 10-14 days of treatment.

Complications: local abscess formation, orbital cellulitis, intracranial extension.

 

Orbital Cellulitis

Epidemiology: All age groups are affected, but average age is 6.8. It affects males twice as often. It is more common in winter months because it is often associated with rhinosinusitis (ethmoiditis) and upper respiratory tract infections.

Microbiology: Staphylococcus and Streptococcus are the two most common etiologies. MRSA is becoming increasingly common. Less commonly, infections can be due to S. milleri, Haemophilus, Neisseria, Bacteroides, and Moraxella catarrhalis.

Symptoms: Fever, proptosis, restriction of extraocular movements, blurred vision, double vision, chemosis, and swelling and redness of the eyelids. Signs of increased intraorbital pressure.

Diagnosis:  IMAGING - Obtain a CT to determine if there is involvement behind the septum
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Treatment: Admit to inpatient care. Clindamycin plus a third generation cephalosporin for 10-14 days. Surgical intervention may be necessary if there are abscesses or increased orbital pressure.

Complications: Cavernous sinus thrombosis, subdural empyema, intracerebral abscess, meningitis, vision loss from septic emboli of optic nerve

 

References

  1. Powell Keith. Orbital and Periorbital Cellulitis. Pediatrics in Review. May 1995
  2. Givner LPeriorbital versus Orbital Cellulitis. Pediatric Infectious Disease. Concise Reviews. December 2002
  3. Givner LB  Pneumococcal Facial Cellulitis Pediatrics 2000;106:e61
  4. E. Wald Periorbital and Orbital Infections.  Pediatrics in Review Sept. 2004
  5. Nield L. and Kamat D. A 9-Year old Who Has Fever, Headache, and Right Eye Pain.  Pediatrics in Review September 2005
  6. Hauser A, Fogarasi S.Periorbital and Orbital Cellulitis.  Pediatrics in Review. June 2010.
  7. Seltz LB et al.  Microbiology and Antibiotic Management of Orbital Cellulitis.  Pediatrics March 2011

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