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Orbital Cellulitis
Tal Marom, M.D.
September 2004
Orbit anatomy
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
In children, orbital cellulitis is usually from a
sinus infection and due to the organism
Hemophilus influenzae (decrease in incidence
after vaccination program implentation).
 Other organisms are Staphlococcus aureus,
Streptococcus pneumoniae, and Beta hemolytic
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, dacryocystorhinostomy,
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 fascial 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
Fever, generally 102 degrees F or greater.
Painful swelling of upper and lower lids (upper is usually
 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 (because the lid is swollen over the eye).
 Eye bulging (forward displacement of the eye).
 Swelling of the eyelids
 General malaise.
 Restricted or painful eye movements
Subperiostal/Orbital abscess (Chandler III-IV)
 Cavernous sinus thrombosis
 Hearing loss
 Septicemia or blood infection
 Meningitis
 Optic nerve damage and blindeness
A male with orbital cellulitis with proptosis,
ophthalmoplegia, and edema and erythema of the eyelids
Non-surgical treatment
 Antifungals (if indicated)
 Nasal decongestants (open sinus ostia)
 Duretics – DIAMOX (carbonic anhydrase
inhibitor), mannitol (reduce IOP)
Surgical Treatment
Surgical drainage if the response to appropriate antibiotic
therapy is poor within 48-72 hours or if the CT scan shows
the sinuses to be completely opacified.
Consider orbital surgery, with or without sinusotomy, in
every case of subperiosteal or intraorbital abscess
Surgical drainage of an orbital abscess is indicated if any
of the following occurs: decrease in vision, An afferent
pupillary defect. 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
If brain abscesses develop and do not respond to antibiotic
therapy, craniotomy is indicated.
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 herniates into sinus defect
 Coronal incision- ethmoidectomy via a superior
approach, more risk for lacrimal sac and trochlea
Inferior Orbit Decompression
Orbital floor blow-out fracture , but spares
infraorbital nerve
 Subcilliary eyelid incision or Caldwell-Luc
 Combined approach?
 Intraorbital fat herniates maxillary sinus
Lateral Orbit Decompression
Lateral canthotomy
 Removal of lateral orbital bone posterior to the
 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 anf medioinferior
floors of orbit
 Endoscopic sinus surgery technique
 Anterior Ethmoidectomy
 Maxillary antrostomy