Eye

Orbital Cellulitis

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Orbital Cellulitis

  • Epidemiology
  1. Mean age: 12 years old
  • Pathophysiology
  1. Bacterial Ethmoid Sinusitis extension to involve orbit (60-80% of cases)
    1. Extends via thin medial bony wall into orbit
    2. Extends via retrobulbar veins (no valves) into lids
  2. Typical Organisms
    1. Streptococcus Pneumoniae
    2. Group A Streptococcus
    3. Staphylococcus aureus
    4. Moraxella catarrhalis
    5. HaemophilusInfluenzae (under age 3 years, decreasing due to Immunization)
    6. Mixed Bacterial Infection including Anaerobes
  3. Organisms in immunocompromised patients (e.g. HIV Infection or AIDS)
    1. Pseudomonas aeruginosa
    2. Opportunistic fungal infections
  • Course
  • Stages
  1. Inflammatory Edema
  2. Orbital Cellulitis
    1. Proptosis
    2. Reduced ocular mobility
  3. Subperiosteal Abscess
  4. Frank Orbital Abscess
  • Signs
  1. Starts as mild inflammatory edema
    1. URI history
    2. Low grade or absent fever
    3. Slowly progressive clinical course
    4. Swollen and discolored Eyelid
  2. Progresses to orbital involvement
    1. Fever
    2. Proptosis (Exophthalmos)
    3. Pain and limitation of eye Extraocular Movement
      1. Key distinguishing feature from Preseptal Cellulitis
    4. Diplopia on side gaze due to inability to move eye
    5. Marcus Gun Pupil (relative afferent pupilary defect)
      1. Swinging Flashlight Test abnormal (affected pupil constricts less in response to light)
    6. Chemosis
    7. Retinal Exam
      1. Venous dilatation and tortuosity
    8. Papilledema
    9. Decreased Visual Acuity
  • Imaging
  1. Modalities
    1. CT Sinuses and orbits with IV Contrast (preferred in most cases) or
    2. MRI sinuses and orbits
  2. Indications: Distinguish preseptal from Orbital Cellulitis (and evaluate sinus involvement)
    1. Change in Visual Acuity
    2. Proptosis
    3. Decreased Extraocular Movements
    4. Diplopia
    5. Eye not able to be examined (e.g. due to local Eyelid Edema)
  • Differential Diagnosis
  1. Preseptal Cellulitis
  2. Orbital pseudotumor
  3. Rhabdomyosarcoma
  4. Neuroblastoma
  5. Leukemia
  6. Lymphoma
  7. Other tumors
    1. Neurofibroma
    2. Glioma of the Optic Nerve
    3. Dermoid cyst
    4. Lymphangioma
    5. Hemangioma
    6. Wilms tumor
  • Management
  1. General
    1. Observe in hospital with at least daily Visual Acuity and Pupillary Light Reflex
    2. Repeat CT sinuses/orbits if not improved in 48 hours
  2. Antibiotics course: 7-14 days
  3. Parenteral antibiotics (initial 2-3 drug regimen)
    1. Antibiotic 1 (choose 1)
      1. Vancomycin 15-30 mg/kg IV every 8-12 hours (preferred) OR
      2. Daptomycin 6 mg/kg IV every 24 hours OR
      3. Linezolid 600 mg IV every 12 hours
    2. Antibiotic 2 (choose 1 )
      1. Piperacillin-Tazobactam 4.5 g IV every 8 hours OR
      2. Ceftriaxone 2 g IV every 24 hours AND Metronidazole 1 g IV every 12 hours OR
      3. Moxifloxicin 400 mg IV every 24 hours (if Penicillin allergic)
  4. Oral antibiotics (once infection controlled and based on microbiology)
    1. See Preseptal Cellulitis management
    2. Consider additional MRSA coverage (e.g. Septra, doxycyline)
    3. Amoxicillin-Clavulanate (Augmentin)
    4. Cefuroxime (Ceftin) or
    5. Cefpodoxime
    6. Cefprozil (Cefzil)
  5. Surgical drainage indications
    1. Large abscess
    2. Significant symptoms
    3. Insufficient improvement on antibiotics
  6. References
    1. (2017) Sanford Guide, accessed on IOS 2/2/2017
    2. Carlisle (2015) Am Fam Physician 92(2): 106-12 [PubMed]
  • Complications
  1. Endophthalmitis (risk of permanent Vision Loss)
  2. Epidural Abscess or subdural abscess
  3. Meningitis
  4. Cavernous Sinus Thrombosis or Dural sinus thrombosis
    1. May present first with Cranial Nerve 6 Palsy (Abducens Nerve palsy), unable to gaze laterally
  • Prognosis
  1. Advanced AIDS
    1. Associated with poor outcomes related to pseudomonas and opportunistic fungal infections
    2. Johnson (1999) Arch Ophthalmol 117(1): 57-64 [PubMed]