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