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Orbital Cellulitis
Orbit anatomy
Frontal
Sphenoid
Nasal
Ethmoid
Lacrimal
Zygoma
Maxillary
Orbital Cellulitis
Orbital cellulitis is a dangerous infection with
potentially serious complications.
It is usually caused by a bacterial infection from
the sinuses (mainly ethmoid, accounting for more
than 90% of all cases)
Other causes :a stye on the eyelid, recent trauma
to the eyelid including bug bites, or a foreign
object
Children
In children, orbital cellulitis is usually from a
sinus infection and due to the organism.
Hemophilus influenza (decrease in incidence
after vaccination program implantation).
Other organisms are Staphylococcus aureus,
Strep.pneumonia, and Beta. H streptococci
Pathophysiology
Extension of infection from the periorbital structures,
most commonly from the paranasal sinuses, but also
from the face, globe, and lacrimal sac.
Direct inoculation of the orbit from trauma or surgery
(orbital decompression, DCR, eyelid surgery,
strabismus surgery, retinal surgery, and intraocular
surgery, have been reported as the precipitating cause
of orbital cellulitis)
Hematogenous spread from bacteremia.
Orbital septum
The orbit is separated from the soft tissue of the eyelid by
the orbital septum. This is a facial plane that is continuous
with the periosteum of the facial bones.
The orbital septum inserts into the tarsal plate of the upper
and lower eyelids.
The orbital septum usually proves to be an effective barrier
that prevents the spread of infection from the eyelids
posteriorly to the orbit.
While preseptal cellulitis can occasionally spread to the
orbital contents, it is generally a clinical entity that is distinct
from orbital cellulitis
Orbital septum
Orbital vs. Preseptal Cellulitis
Orbital cellulitis is infection of the soft tissues
of the orbit posterior to the orbital septum,
differentiating it from preseptal cellulitis,
which is infection of the soft tissue of the
eyelids and periocular region anterior to the
orbital septum
DD: orbital pseudotumor (inflammatory
condition, responds to steroids)
Chandler Classification
Stage I
Stage II
Stage III
Stage IV
Stage V
Inflammatory edema-Preseptal
Orbital cellulitis - Postseptal
Subperiostal abscess
Orbital abscess
Complication due to posterior
extension
Symptoms
Fever, generally 39 degrees C or greater.
Eyelid appears shiny and is red or purple in color.
Infant or child is acutely ill or toxic.
Eye pain especially with movement.
Decreased vision
proptosis
Painful swelling of the eyelids
General malaise.
Restricted or painful eye movements
Complications
Subperiostal/Orbital abscess
Cavernous sinus thrombosis
Hearing loss
Septicemia
Meningitis
Optic nerve damage and blindness
A male with orbital cellulitis with proptosis,
ophthalmoplegia, eyelids edema and erythema .
Non-surgical treatment
IV ABx
Antifungal (if indicated)
Nasal decongestants (open sinus ostia)
Diuretics – DIAMOX (carbonic anhydrase
inhibitor), manitol.
Surgical Treatment
Surgical drainage if failed response to appropriate
antibiotic within 48-72 h .
Every case of subperiosteal or intraorbital abscess
formation.
Decrease V/A, RAPD. proptosis progresses despite
appropriate antibiotic therapy
The size of the abscess does not reduce on CT scan
within 48-72 hours after appropriate antibiotics have
been administered.
If brain abscesses develop and do not respond to
antibiotic therapy, craniotomy is indicated.
How?
Superior orbit decompression
Medial orbit decompression
Inferior orbit decompression
Lateral orbit decompression
Intranasal approach
Superior Orbit Decompression
Frontal cranioitomy –
unroofing of superior
wall of orbit
Titanium sheild placed to
support the frontal lobe
of the brain
High morbidity, consider
only for severe cases
Medial Orbit Decompression
External ethmoidectomy incision or coronal
forehead approach
External ethmoidectomy- complete ethmoid sinus
resection, then orbital fat herniated into sinus defect
Coronal incision- ethmoidectomy via a superior
approach, more risk for lacrimal sac and trochlea
injury
Inferior Orbit Decompression
Orbital floor blow-out Fx ,but spares infraorbital
nerve.
Subciliary eyelid incision or Caldwell-Luc
incision
Combined approach?
Intraorbital fat herniates maxillary sinus
Lateral Orbit Decompression
Lateral canthotomy
Removal of lat. orbital bone posterior to the rim
Orbital fat protrudes the newly created space
An incision extending from the lateral canthus to the
area just below the inferior punctum is created 4 mm to
5 mm below the lower border of the tarsal plate to avoid
injury to the septum and the canaliculus
Intranasal approach
Decompression of medial and medioinferior
floors of orbit.
Endoscopic sinus surgery technique.
Anterior Ethmoidectomy
Maxillary antrostomy