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Periorbital and Orbital Cellulitis Adaobi Okobi, M.D. Pediatrics Chief Resident St. Barnabas Hospital Objectives Differentiate between periorbital and orbital cellulitis based on history and physical exam Discuss the causes and treatments of periorbital and orbital cellulitis Review the indications for imaging and ophthalmology consultation for eyelid swelling Recognize the complications of periorbital and orbital cellulitis Simplified anatomy of the eye, paranasal sinuses, and venous drainage Hauser, A. et al. Pediatrics in Review 2010;31:242-249 Copyright ©2010 American Academy of Pediatrics Pathogenesis Sinusitis Extension of external ocular infection (ie hordeolum, dacryocystitis/dacroadenitis) Dental abscess Superficial break in the skin (ie infected bug bite, acne, eczema, periocular surgery or direct penetrating trauma) Hematogenous spread Organisms Haemophilus influenza type b (before Hib vaccine in 1985) Staphylococcus aureus (including MRSA) S. epidermidis Streptococcus pyogenes History Past sinus disease? Past dental disease? Previous eye surgery? History of trauma? Physical Exam Observe for degree of ocular swelling Assess extraocular movement Evaluate for foreign body Assess visual acuity Clinical Signs and Symptoms Unilateral erythema of eyelid Swelling of eyelid Warmth of eyelid Tenderness of eyelid Blurred vision Ophthalmoplegia Proptosis Chemosis Imaging: Indications Eyelid edema that makes a complete examination impossible Presence of CNS involvement (ie seizures, focal neurologic deficits, or altered mental status) Deteriorated visual acuity or color vision Proptosis Ophthalmoplegia Clinical worsening or no improvement after 24-48 hours A 15-month-old girl who has periorbital cellulitis and fever following infection of an insect bite to her lower right eyelid despite treatment with several days of cephalexin Hauser, A. et al. Pediatrics in Review 2010;31:242-249 Copyright ©2010 American Academy of Pediatrics An 11-year-old boy who has pan-sinusitis and left orbital cellulitis and presented with fever, severe left eye pain, proptosis, chemosis, and limitation of extraocular movements Hauser, A. et al. Pediatrics in Review 2010;31:242-249 Copyright ©2010 American Academy of Pediatrics Differential Diagnosis Allergic reaction Edema from hypoproteinemia Orbital wall infarction Subperiosteal hematoma Orbital pseudotumor Orbital myositis Retinoblastoma Metastatic carcinoma Exophthalmos secondary to thyroid dysfunction Admission Criteria Patients with orbital cellulitis presenting with: Eyelid edema Diplopia Reduced visual acuity Abnormal light reflexes Ophthalmoplegia Proptosis Appears toxic Eye exam is unable to be completely performed Signs of CNS involvement: Lethargy Vomiting Seizures Headache Cranial nerve deficit Management Depends on the patient’s appearance, ability to take oral medications, compliance and clinical progression of the disease Empiric antibiotics should cover Staphylococcus and Streptococcus species, particularly MRSA Treat for 7-10 days for periorbital cellulitis Treat for 10-14 days for orbital cellulitis If no improvement in 24-48 hours consider consulting Infectious Disease, ophthalmology, ENT and/or neurosurgery Management Obtain blood culture in younger patients or those that appear systemically ill Culture ocular discharge Obtain orbital, epidural absces or sinus fluid if patient requires surgery Include a sepsis evaluation if the patient appears toxic or has neurologic involvement Complications Local abscess formation Orbital cellulitis Intracranial extension of infection (eg subdural empyema, intracerebral abscess, extradural abscess and meningitis) Cavernous venous sinus thrombosis Septic emboli of the optic nerve Optic nerve ischemia (due to compression) may result in visual loss Summary Orbital cellulitis is an emergency that requires prompt diagnosis and evaluation by ophthalmology Periorbital cellulitis and orbital cellulitis have distinct differences that can be elicited by careful history and physical examination If the physical exam cannot be fully completed for any reason, radiologic imaging is required Patients with systemic illness or evidence of orbital cellulitis or neurologic involvement require inpatient admission Improvement should occur within 24-48 hours with antibiotics Questions A 6 year old child is brought to the emergency department by his parents because of upper respiratory tract symptoms, a progressively swollen left eye, and altered mental status. He has been otherwise healthy and is fully immunized. Upon examination, he is difficult to arouse. Local signs include a markedly swollen left eye with proptosis. Eye movements are difficult to assess because of the boy’s poor neurologic status. He is febrile, but hemodynamically stable. The most likely pathogenesis is: A. Acute bacterial meningitis, with secondary infection of the left orbit B. Bacteremia causing both ocular and intracranial illness C. Head trauma, with ocular and intraocular manifestations D. Intracranial mass causing ocular and neurologic manifestations E. Orbital cellulitis, with the neurologic complication of bacterial meningitis Questions A father calls your office to report that his 2 year old daughter has had nasal congestion and fever for the past 2 days. She received a nonprescription medication this morning, and today her right eye is “swollen shut”. When she arrives in your office, she is febrile but nontoxic. Her right eyelids are swollen and erythematous. It is nearly impossible to determine whether her extraocular movements are normal, but she exhibits increased tearing of the affected eye. Of the following, the most reasonable diagnosis and plan of treatment are: A. Allergic reaction and trial of antihistamine at home B. Periorbital cellulitis and IV antibiotics and CT scan of the orbits C. Periorbital cellulitis and ophthalmology consultation and IV antibiotics D. Periorbital cellulitis and oral antibiotics at home E. Reactive periorbital swelling from sinusitis and nasal decongestant at home References Hauser, A and Fogarasi, S. Periorbital and Orbital Cellulitis. Pediatrics in Review. 2010;31:242249
