Difference between revisions of "Orbital Cellulitis"

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{{Article
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|Authors=Louise.A.Mawn.CMT
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|Additional contributors=Gloria.hong,Pauline.Dmitriev
[[Image:Orbital cellulitis1.jpg|thumb|center]]8-month old with recent upper respiratory infection and orbital cellulitis. Infection resolved with intravenous antibiotics.  
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|Category=Articles, Oculoplastics/Orbit, Pediatric Ophthalmology/Strabismus
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|Assigned editor=Louise.A.Mawn.CMT,Carla.osigian
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|Reviewer=Grace.Prakalapakorn
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|Date reviewed=January 5, 2021
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|Article status=Up to Date
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}}
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{{Infobox disease
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| Name = {{PAGENAME}}
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| Image = Orbital cellulitis1.jpg
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| Caption = 8-month old with recent upper respiratory infection and orbital cellulitis. Infection resolved with intravenous antibiotics.
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| Alt = 8-month old with recent upper respiratory infection and orbital cellulitis. Infection resolved with intravenous antibiotics.
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| DiseasesDB = 9249
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| ICD9 = {{ICD9|376.01}}
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}}
  
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= Disease Entity  =
 
= Disease Entity  =
  
Orbital cellulitis is an inflammation of the soft tissues of the eye socket behind the orbital septum, a thin tissue which divides the eyelid from the eye socket. Orbital cellulitis most commonly refers to an acute spread of infection into the eye socket from either the adjacent sinuses, skin or from spread through the blood.   
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Orbital cellulitis is an infection of the soft tissues of the eye socket behind the orbital septum, a thin tissue which divides the eyelid from the eye socket. Infection isolated anterior to the orbital septum is considered to be [[preseptal cellulitis]]. Orbital cellulitis most commonly refers to an acute spread of infection into the eye socket from either extension from periorbital structures (most commonly the adjacent ethmoid or frontal sinuses (90%), skin, dacryocystitis, dental infection, intracranial infection), exogenous causes (trauma, foreign bodies, post-surgical), intraorbital infection (endopthalmitis, dacryoadenitis), or from spread through the blood (bacteremia with septic emboli).   
  
 
== Disease  ==
 
== Disease  ==
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== Etiology  ==
 
== Etiology  ==
  
Orbital cellulitis most commonly occurs when bacterial infection spreads from the paranasal sinuses. It can also occur when an eyelid skin infection or an infection in an adjacent area spreads to the orbit or from an infection in the blood system.  
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Orbital cellulitis most commonly occurs when a bacterial infection spreads from the paranasal sinuses into the orbit. In children under the age of 10 years, paranasal sinusitis most often involves the ethmoid sinus which spreads through the thin lamina papyracea of the medial orbital wall into the orbit. It can also occur when an eyelid skin infection, an infection in an adjacent area, or an infection in the blood stream spreads into the orbit. The drainage of the eyelids and sinuses occurs largely through the orbital venous system: more specifically, through the superior and inferior orbital veins that drain into the cavernous sinus. This venous system is devoid of valves and for this reason infection might spread, in preseptal and orbital cellulitis, into the cavernous sinus causing a sight threatening complication such as cavernous sinus thrombosis.
  
 
== Risk Factors  ==
 
== Risk Factors  ==
  
Risk factors include recent upper respiratory illness, acute or chronic bacterial sinusitis, recent trauma, recent ocular or periocular infection, or systemic infection.  
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Risk factors include recent upper respiratory illness, acute or chronic bacterial sinusitis, trauma, ocular or periocular infection, or systemic infection.  
  
 
== General Pathology  ==
 
== General Pathology  ==
  
The orbital tissues are infiltrated by acute and chronic inflammatory cells and the infectious organisms may be identified on the tissue sections. The organisms are best identified by microbiologic culture. The most common infectious pathogens include gram positive streptococcal and staphylococcal species. In children younger than 9, the infections are typically from one organism; in children older than 9 and in adults, the infections may be polymicrobial with both aerobic and anaerobic bacteria.  
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Orbital cellulitis can be caused by an extension from periorbital structures (paranasal sinuses, face and eyelids, lacrimal sac, dental structures). Its cause can also be exogenous (trauma, foreign body, surgery), endogenous (bacteremia with septic embolization), or intraorbital (endophthalmitis, dacryoadenitis).<ref name="BCSC1">Basic and Clinical Science Course 2019-2020: Oculofacial Plastic and Orbital Surgery. San Francisco, CA: American Academy of Ophthalmology; 2019. </ref> The orbital tissues are infiltrated by acute and chronic inflammatory cells and the infectious organisms may be identified on the tissue sections. The organisms are best identified by microbiologic culture. The most common infectious pathogens include gram positive Streptococcal and Staphylococcal species. In a landmark article by Harris et al, it was noted that in children younger than 9 years of age, the infections are typically from one aerobic organism; in children older than 9 years of age and in adults, the infections may be polymicrobial with both aerobic and anaerobic bacteria.<ref name="harris1">Harris GJ. Subperiosteal abscess of the orbit. Age as a factor in the bacteriology and response to treatment. Ophthalmology 1994;101(3):585-95. </ref>
  
The most common pathogens in orbital cellulitis, strep and staph are both gram positive. Streptococcal infections are identified on culture by their formation of pairs or chains. Streptococcal pyogenes (Group A Strep) requires blood agar to grow and exhibits clear (beta) hemolysis on blood agar. Streptococcus such as streptococcus pneumonia produce Green (alpha) hemolysis, or partial reduction of red blood cell hemoglobin. Staphyloccal species show a cluster arrangement on gram stain. Staphylococcus aureus forms a large yellow colony on rich medium in distinction to Staphylococcus epidermidis which forms white colonies. Gram negative rods can be seen in both orbital cellulitis related to trauma and in some older children or adults. Anaerobic bacteria such as peptococcus, peptostreptococcus, bacteroides can be involved in infections extending from sinusitis in adults or older children. Fungal infections with either mucor or aspergillus need to be considered in immunocompromised or diabetic patients; immunocompetent patients may also have fungal infections in rare cases.  
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The most common pathogens in orbital cellulitis are gram positive Strep and Staph species. Streptococcal infections are identified on culture by their formation of pairs or chains. ''Streptococcal pyogenes'' (Group A Strep) requires blood agar to grow and exhibits clear (beta) hemolysis on blood agar. Streptococcus such as ''Streptococcus pneumonia'' produce green (alpha) hemolysis, or partial reduction of red blood cell hemoglobin. Staphylococcal species appear as a cluster arrangement on gram stain. ''Staphylococcus aureus'' forms a large yellow colony on rich medium in distinction to ''Staphylococcus epidermidis'' which forms white colonies. Gram negative rods can be seen in both orbital cellulitis related to trauma and in neonates and immunosuppressed patients. Anaerobic bacteria such as Peptococcus, Peptostreptococcus, and Bacteroides can be involved in infections extending from sinusitis in adults and older children. Fungal infections with either Mucor or Aspergillus need to be considered in immunocompromised or diabetic patients; immunocompetent patients may also have fungal infections in rare cases.  
 
 
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== Pathophysiology  ==
 
== Pathophysiology  ==
  
Orbital cellulitis most commonly occurs in the setting of an upper respiratory or sinus infection. The human upper respiratory tract is normally colonized with Strep pneumoniae and infection can occur through several mechanisms. Strep pyogenes infections also occur primarily in the respiratory tract. The complex cell surface of this gram positive organism determines its virulence and ability to invade the surrounding tissue and incite inflammation. Staph aureus infections occur commonly in the skin and spread to the orbit from the skin. Staphylococcal organisms also produce toxins which help to promote their virulence and leads to the inflammatory response seen in these infections. Staph epi can produce a biofilm accounting for involvement in implant related infections. The inflammatory response elicited by all these pathogens plays a major role in tissue destruction in the orbit.  
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Orbital cellulitis most commonly occurs in the setting of an upper respiratory or sinus infection. The human upper respiratory tract is normally colonized with ''Strep pneumoniae'' and infection can occur through several mechanisms. ''Strep pyogenes'' infections also occur primarily in the respiratory tract. The complex cell surface of this gram-positive organism determines its virulence and ability to invade the surrounding tissue and incite inflammation. ''Staph aureus'' infections occur commonly in the skin and spread to the orbit from the skin. Staphylococcal organisms also produce toxins which help to promote their virulence and leads to the inflammatory response seen in these infections. The inflammatory response elicited by all these pathogens plays a major role in tissue destruction in the orbit.  
  
 
== Primary prevention  ==
 
== Primary prevention  ==
  
Identifying patients and effectively treating upper respiratory or sinus infections before they evolve into orbital cellulitis is an important aspect of preventing preseptal cellulitis from progressing to orbital cellulitis. Equally important in preventing orbital cellulitis is prompt and appropriate treatment of preseptal skin infections or even odentogenic infections before they spread into the orbit.  
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Identifying patients and effectively treating upper respiratory or sinus infections before they evolve into orbital cellulitis is an important aspect of preventing preseptal cellulitis from progressing to orbital cellulitis. Equally important in preventing orbital cellulitis is prompt and appropriate treatment of preseptal skin infections as well as infections of the teeth, middle ear, or face before they spread into the orbit.  
  
 
= Diagnosis  =
 
= Diagnosis  =
 
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The diagnosis of orbital cellulitis is based on clinical examination. The presence of the following signs is suggestive of orbital involvement: proptosis, chemosis, pain with eye movements, ophthalmoplegia, optic nerve involvement as well as fever, leukocytosis  (75% of cases), and lethargy. Other signs and symptoms include rhinorrhea, headache, tenderness on palpation, and eyelid edema. Intraocular pressure may be elevated if there is increased venous congestion. In addition to clinical suspicion, diagnostic imaging using computed tomography (CT)  may help distinguish between preseptal and orbital cellulitis while also looking for complications of orbital cellulitis (see below).
A critical determinant in evaluation a patient with periorbital complaints is to determine if the infection involves only the most superficial tissues of the eyelids or has progressed to involve the orbit. The comprehensive evaluation (history and physical examination) includes those components of the comprehensive medical eye evaluation specifically relevant to the diagnosis and treatment of an orbital process as listed below.  
 
  
 
== History  ==
 
== History  ==
 
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The presence of a painful red eye, with lid edema in a child with a recent upper respiratory infection is the typical presentation of orbital cellulitis. Patient history should also include the presence of headache, orbital pain, double vision, progression of symptoms, recent upper respiratory symptoms (e.g. nasal discharge or stuffiness), pain over sinuses, fever, lethargy, recent periocular trauma or injury, family or health care contacts with Methicillin-resistant ''Staphylococcus aureus'' (MRSA), history of sinus, ear, dental, or facial infections or surgery, recent ocular surgery, pertinent medical conditions, medications currently used, as well as the presence of diabetes mellitus and the immune status of the patient. Specific questions regarding any change in vision, mental status, pain with neck movement, or nausea or vomiting should also be asked.  
Patient history, including the patient’s assessment of visual status, headache, orbital pain, double vision, progression of symptoms, recent upper respiratory symptoms including nasal discharge or stuffiness, pain over sinuses, fever, lethargy, recent periocular trauma or injury, family or health care contacts with MRSA, history of sinus, ear, or facial infections or surgery, recent ocular surgery, pertinent medical conditions, medications currently used, and other risk factors that can affect the surgical plan or outcome of surgery (e.g., immunosuppressive conditions, diabetes). Specific questions regarding any change in mental status, pain with neck movement, or nausea or vomiting should be asked.  
 
  
 
== Physical examination  ==
 
== Physical examination  ==
  
*Visual acuity with current correction (the power of the present correction recorded) at distance and when appropriate at near or pinhole vision in some emergency room settings.  
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The physical examination should include:
*Color vision assessment  
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*Best-corrected visual acuity (BCVA). Decreased vision might be indicative of optic nerve involvement or could be secondary to severe exposure keratopathy or retinal vein occlusion.
*Visual field assessment with confronation fields
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*Color vision assessment to assess the presence of optic nerve involvement.
*Assessment of pupillary function with particular attention paid to any relative afferent pupillary defect.  
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*Proptosis measurements using Hertel  exophthalmometry.
*External examination (lids, lashes, lacrimal apparatus, orbit). o Position and function of lids, erythema, swelling of lids, discharge on lashes,  
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*Visual field assessment via confrontation.
**Orbit exam should include documentation of direction of displacement of globe (a superior subperiosteal abscess will displace the globe inferiorly), resistance to retropulsion on palpation, unilateral or bilateral involvement  
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*Assessment of pupillary function with particular attention paid to the presence of  a relative afferent pupillary defect (RAPD).
**Evaluation of lacrimal gland should discern whether any injection or purulence is present.  
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*Ocular motility and presence of pain with eye movements. Also, there might be involvement of the III, IV, and V1/V2 cranial nerve in cases of cavernous sinus involvement.
*Examination of ocular alignment and motility.  
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*Orbit exam should include documentation of direction of displacement of globe (e.g. a superior subperiosteal abscess will displace the globe inferiorly), resistance to retropulsion on palpation, unilateral or bilateral involvement (bilateral involvement is virtually diagnostic of cavernous sinus thrombosis<ref name="BCSC2">Basic and Clinical Science Course 2019-2020: Pediatric Ophthalmology and Strabismus. San Francisco, CA: American Academy of Ophthalmology; 2019. </ref>).  
*Measurement of intraocular pressure (IOP).  
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*Measurement of intraocular pressure (IOP). Increased venous congestion may result in increased IOP.  
*Slit-lamp biomicroscopy of the anterior segment if possible.  
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*Slit-lamp biomicroscopy of the anterior segment if possible to look for signs of exposure keratopathy in cases of severe proptosis.
*Dilated examination of the lens, macula, peripheral retina, optic nerve, and vitreous.  
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*Dilated fundus exam will exclude or confirm the presence of optic neuropathy or retinal vascular occlusion.
*Assessment of relevant aspects of the patient’s mental and physical status.
 
 
 
<br>
 
 
 
 
== Signs  ==
 
== Signs  ==
  
As a preseptal infection progresses into the orbit, the inflammatory signs typically increase with increasing redness and swelling of the eyelid with a secondary ptosis. As the infection worsens, proptosis develops and extraocular motility becomes compromised. When the optic nerve is involved, loss of visual acuity is noted and an afferent pupillary defect can be appreciated. The intraocular pressure often increases and the orbit becomes resistant to retropulsion. The skin can feel warm to the touch and pain can be elicited with either touch or eye movements.  
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As a preseptal infection progresses into the orbit, the inflammatory signs typically increase with increasing redness and swelling of the eyelid with a secondary ptosis. As the infection worsens, proptosis develops and extraocular motility becomes compromised. When the optic nerve is involved, loss of visual acuity is noted and an afferent pupillary defect can be appreciated. The intraocular pressure often increases and the orbit becomes resistant to retropulsion. The skin can feel warm to the touch and pain can be elicited with either touch or eye movements. Examination of  the nose and mouth is also warranted in order to look for any black eschar which would suggest a fungal infection. Purulent nasal discharge with hyperemic nasal mucosa may be present. 
  
 
== Symptoms  ==
 
== Symptoms  ==
  
Systemic symptoms including fever and lethargy may or may not be present. Change in the appearance of the eyelids with redness and swelling is frequently a presenting symptom. Pain, particularly with eye movement, is commonly noted. Double vision may occur once orbital cellulitis has developed. Decreased vision or change in vision is a symptom suggestive of optic nerve compromise.  
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Systemic symptoms including fever and lethargy may or may not be present. Change in the appearance of the eyelids with redness and swelling is frequently a presenting symptom. Pain, particularly with eye movement, is commonly noted. Double vision may also occur.  
  
== Clinical diagnosis ==
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== Diagnostic procedures ==
  
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Computed tomography (CT) of the orbit is the imaging modality of choice for patients with orbital cellulitis. Most of the time, CT is readily available and will give the clinician information regarding the presence of  sinusitis, subperiosteal abscess, stranding of orbital fat, or intracranial involvement. Nevertheless, in cases of mild to moderate orbital cellulitis with no optic nerve involvement, the initial management of the patient remains medical. Imaging is warranted in children and in cases of poor response to intravenous antibiotics with progression of orbital signs in order to confirm the presence of complications such as subperiosteal abscess or intracranial involvement. Although a magnetic resonance imaging (MRI) scan is safer in children since there is no risk of radiation exposure, the long acquisition time and the need for prolonged sedation make CT scan the imaging modality of choice. However, if there is suspicion of a concomitant cavernous sinus thrombosis, MRI may be a useful adjunct to a CT scan.
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[[Image:Orbital cellulitis2.jpg|thumb|center]]Computed tomograph of a 5 year old with subperiosteal abscess in right medial orbit.<br> [[Image:Orbital cellulitis3.jpg|thumb|center]]Coronal computed tomogram of a 10 year old with a large subperiosteal abscess of the orbital roof requiring emergent surgical drainage.  
 
  
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== Laboratory test  ==
 
 
The clinical diagnosis is established by both the history and the examination. The history supports the diagnosis particularly when a recent upper respiratory infection or eyelid infection has been reported. Signs which suggest the orbit is involved include warmth, redness and swelling of the eyelids, proptosis or bulging of the eye, limitation of eye movement, decrease in vision, afferent pupillary defect, and increased pressure in the orbit. Examination may include the nose and mouth to look for any black eschar which would suggest a fungal infection. Imaging studies are critical in determining the extent of orbital involvement and the risk to vision and the intracranial structures. It is often not possible to differentiate early orbital cellulitis from preseptal cellulitis and a low threshold for imaging should exist.
 
  
== Diagnostic procedures  ==
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Admission to the hospital is warranted in all cases of orbital cellulitis. A complete blood count with differential, blood cultures, and nasal and throat swabs should be ordered.
  
Computed tomography of the orbit, with axial and coronal cuts, to look for adjacent sinusitis with subperiosteal abscess, stranding of orbital fat, or an orbital abscess needs to be performed. The location and extend of any abscess needs to be carefully assessed and documented. Abscesses along the roof, or extending into the posterior orbit can be indications for emergent surgical drainage. In some patients magnetic resonance imaging may give further information regarding intracranial involvement.<br> <br> <br>
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==Differential Diagnosis==
  
== Laboratory test  ==
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The differential diagnosis includes:
  
A complete blood count and differential along with a complete metabolic profile should be completed. If systemic symptoms or a febrile illness are associated with the orbital changes, blood cultures should be sent. If meningeal signs are present or an intracranial infection suspected, a lumbar puncture should be performed. If any purulent drainage is present from a wound or the conjunctiva or nasal passages it should be swabbed and sent for culture. If an abscess is drained then the fluid should be sent for both anaerobic and aerobic culture; if fungal infection is suspected then these too should be sent. In certain presentations, cultures for acid fast bacilli should also be sent. Any tissue biopsied should be sent separately for both histopathological evaluation as well as microbiology evaluation.
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*Idiopathic inflammation/specific inflammation (e.g. orbital pseudotumor, granulomatosis with polyangiitis, sarcoidosis)
  
== Differential diagnosis  ==
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*Neoplasia (e.g. lymphangioma, hemangioma, leukemia, rhabdomyosarcoma, lymphoma, retinoblastoma, metastatic carcinoma)
  
• Orbital Pseudotumor • Acute Thyroid Eye Disease • Orbital Tumor • Allergic Reaction • Dacryocystitis • Dacryoadenitis
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*Trauma (e.g. retrobulbar hemorrhage, orbital emphysema)
  
<br>
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*Systemic diseases (e.g sickle cell disease with bony infarcts and subperiosteal hematomas)
  
 +
*Endocrine disorders (e.g. thyroid ophthalmopathy)
 
= Management  =
 
= Management  =
 
The management of any abscess is surgical drainage with intravenous antibiotics. There are select cases of orbital cellulitis in children younger than the age of 9 who meet strict criteria who may be considered for medical management. These criteria are discussed below. Once treated with medical management, prompt improvement observed on serial frequent examinations must be documented. Imaging changes may lay the clinical improvement and the decision for surgical intervention should be based on clinical assessment rather than on imaging features. Antibiotic choice is very much dependent on the organisms suspected to be involved in the infection.
 
  
 
== General treatment  ==
 
== General treatment  ==
  
General treatment involves intravenous antibiotics and frequent evaluations for improvement or progression. This is typically best accomplished as a hospital in patient. Examination by an ophthalmologist establishes the vision function and threat. Orbital cellulitis can progress to blindness, cavernous sinus thrombosis, intracranial abscess and death. It is aggressively treated as an ophthalmic emergency. Computed tomography helps to establish the location and extent of the disease and the status of periorbital structures, such as the brain and sinuses. Laboratory evaluation with complete blood count, differential, wound cultures, blood cultures if septic and lumbar puncture if neurologic compromise should be performed. A low threshold for surgical intervention should exist. Conservative management with intravenous antibiotics, nasal toilet with decongestants in patients with nasal or sinus disease, and frequent re-evaluation may considered for patients with no orbital abscess, or in children with small, anterior, medial subperiosteal abscesses without posterior extent or visual compromise. When pansinusistis, intracranial involvement, a large abscess, threat to the posterior orbit or orbital roof, intraorbital gas, or visual compromise exist surgical intervention needs to be promptly performed.
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The management of orbital cellulitis requires admission to the hospital and initiation of broad-spectrum intravenous antibiotics that address the most common pathogens. Blood cultures and nasal/throat swabs should be undertaken, and the antibiotics should be modified based on the results. In infants with orbital cellulitis, a 3rd generation cephalosporin is usually initiated such as cefotaxime, ceftriaxone or ceftazidime along with a penicillinase-resistant penicillin. In older children, since sinusitis is most commonly associated with aerobic and anaerobic organisms, clindamycin might be another option. Metronidazole is also being increasingly used in children. If there is concern for MRSA infection, vancomycin may be added as well.<ref>Liao, S., Durand, M. L., & Cunningham, M. J. (2010). Sinogenic orbital and subperiosteal abscesses: Microbiology and methicillin-resistant Staphylococcus aureus incidence. ''Otolaryngology–Head and Neck Surgery'', ''143''(3), 392–396.</ref> As mentioned before, the antibiotic regimen should be  modified based on the results of the cultures if needed. The patient should be followed closely in the hospital setting for progression of orbital signs and development of complications such as cavernous sinus thrombosis or intracranial extension, which can be lethal.<ref name="BCSC2">Basic and Clinical Science Course 2019-2020: Pediatric Ophthalmology and Strabismus. San Francisco, CA: American Academy of Ophthalmology; 2019. </ref> Once improvement has been documented with 48 hours of intravenous antibiotics, consideration for switching to oral antibiotics may be appropriate.
 
 
== Medical therapy ==
 
 
 
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[[Image:Orbital cellulitis5.jpg|thumb|center]]Rapidly progressive orbital cellulitis from MRSA skin infection. [[Image:Orbital cellulitis4.jpg|thumb|center]] Intraoperative photograph shows the yellow purulence characteristic of Staph infections.
 
 
 
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Emperic coverage with antibiotics needs to consider the possible bacterial pathogens involved. Respiratory infections are commonly caused by gram positive Strep and Staph along with anaerobic bacteria. Penicillins are still effective in the treatment of group A strep infections such as Strep pyogenes. Options for coverage include both penicillins and cephalosporins for these infections. Drug resistance has developed in staphylococci and this is seen most prominently in the recent rise in Methicillin resistent Staph aureus orbital cellulitis. Coverage for suspected MRSA may be warranted particularly if any recent contacts with MRSA positive individuals, health care workers or if orbital cellulitis has progressed from a skin infection. In most communities, intravenous Vancomycin shows effective coverage for MRSA. Alternatives MRSA coverage may include Clindamycin, Doxycycline, or Trimethoprim/Sulfamethoxizole. Once improvement has been documented with 48 hours of intravenous antibiotics, consideration for switching to oral antibiotics may be appropriate. Often 2-3 weeks of oral antibiotics are necessary. In complex or posterior infection, prolonged treatment with intravenous antibiotics or oral antibiotics may be required. Consultation with an infectious disease specialist may be required.
 
 
 
 
== Medical follow up  ==
 
== Medical follow up  ==
  
In hospital patients on medical management are often seen every 4-6 hours to determine if their status is worsening. Once the threat to vision or neurologic status has cleared, they are then seen daily to confirm improvement. Once vision and the orbit is stable hospital discharge is arranged with follow up within 7-10 days of discharge with clear instructions that if symptoms or signs return or vision changes, the patient must immediately return to the emergency room or clinic.  
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A multi-disciplinary approach is usually warranted for patients with orbital cellulitis under the care of pediatricians, ENT surgeons, ophthalmologists, and infectious disease specialists.
  
 
== Surgery  ==
 
== Surgery  ==
  
Surgery is performed for any abscess that threatens vision or neurologic status. Typically sinus drainage is performed concurrently for any significant sinus disease. If a small or modest subperiosteal abscess is present in the medial orbit, the drainage can be performed endoscopically during the sinus drainage. Orbital approaches include transcaruncular to the medial orbit, a Lynch incision to the medial orbit, a swinging eyelid flap to the floor, or an upper lid crease incision to the superior orbit. All of these surgical approaches can provide excellent post-operative cosmesis.
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The prevalence of subperiosteal or orbital abscess complicating an orbital cellulitis approaches 10%. The clinician should suspect the presence of such an entity if there is progression of orbital signs, and/or systemic compromise despite the initiation of appropriate intravenous antibiotics for at least 24-48 hours. In these cases, a contrast-enhanced CT scan should be ordered to evaluate the orbit, the paranasal sinuses, and/or the brain. If there is associated sinusitis, ENT should be consulted. If an orbital abscess is present it should be drained. The management of subperiosteal abscess remains controversial since there are cases of resolution with the use of intravenous antibiotics only. As a general recommendation (as initially described by Garcia and Harris), observation with intravenous antibiotics only (i.e. no drainage of the subperiosteal abscess) is indicated when:
  
== Surgical follow up  ==
+
* Child is under the age of 9 years
 +
* No intracranial involvement
 +
* Medial wall abscess is of moderate or smaller size
 +
* No vision loss or afferent pupillary defect
 +
* No frontal sinus involvement
 +
* No dental abscess
  
While in hospital, initial surgical follow up includes post-operative day 1 check and then as dictated by the clinical situation. Patients are often seen back in the office in 1-2 weeks or earlier should there be any recurrence of symptoms or signs.  
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If there is evidence of intracranial extension of the infection, evidence of optic nerve compromise, clinical deterioration despite 48 hours of intravenous antibiotics, suspicion of anaerobic infection (e.g. presence of gas in abscess on CT), or recurrence of subperiosteal abscess after prior drainage, surgery is almost always indicated.<ref name="BCSC1">Basic and Clinical Science Course 2019-2020: Oculofacial Plastic and Orbital Surgery. San Francisco, CA: American Academy of Ophthalmology; 2019. </ref> At the time of surgery, cultures and susceptibility testing may be obtained from samples to help tailor therapy.
  
 
== Complications  ==
 
== Complications  ==
  
The complications of orbital cellulitis are ominous and include blindness, cavernous sinus thrombosis, intracranial brain abscess, and death.  
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The complications of orbital cellulitis are ominous and include severe exposure keratopathy with secondary ulcerative keratitis, neutrophic keratitis, secondary glaucoma, septic uveitis or retinitis, exudative retinal detachment, inflammatory or infectious neuritis, optic neuropathy, panophthalmitis, cranial nerve palsies, optic nerve edema, subperiosteal abscess, orbital abscess, central retinal artery occlusion, retinal vein occlusion, blindness, orbital apex syndrome, cavernous sinus thrombosis, meningitis, subdural or brain abscess, and death.
  
 
== Prognosis  ==
 
== Prognosis  ==
  
With prompt recognition and aggressive medical and surgical treatment the prognosis can be excellent.  
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With prompt recognition and aggressive medical and/or surgical treatment, the prognosis is excellent.  
  
 
= Additional Resources  =
 
= Additional Resources  =
 +
* Boyd K,  Lipsky SN. [https://www.aao.org/eye-health/diseases/what-is-cellulitis-list Cellulitis ]. American Academy of Ophthalmology. EyeSmart<sup>®</sup> Eye health. https://www.aao.org/eye-health/diseases/what-is-cellulitis-list. Accessed March 07, 2019.
  
http://www.aao.org/theeyeshaveit/red-eye/orbital-cellulitis.cfm
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* http://www.ophthalmology.theclinics.com/article/s0896-1549(05)70221-2/abstract
 
 
http://www.ophthalmology.theclinics.com/article/s0896-1549(05)70221-2/abstract  
 
  
 
= References  =
 
= References  =
 
+
<references />
Brook I. Role of methicillin-resistant Staphylococcus aureus in head and neck infections. J Laryngol Otol 2009;123(12):1301-7.  
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# Brook I. Role of methicillin-resistant Staphylococcus aureus in head and neck infections. J Laryngol Otol 2009;123(12):1301-7.
 
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# Cannon PS, Mc Keag D, Radford R, et al. Our experience using primary oral antibiotics in the management of orbital cellulitis in a tertiary referral centre. Eye (Lond) 2009;23(3):612-5.
Cannon PS, Mc Keag D, Radford R, et al. Our experience using primary oral antibiotics in the management of orbital cellulitis in a tertiary referral centre. Eye (Lond) 2009;23(3):612-5.  
+
# Fu SY, Su GW, McKinley SH, Yen MT. Cytokine expression in pediatric subperiosteal orbital abscesses. Can J Ophthalmol 2007;42(6):865-9.
 
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# Garcia GH, Harris GJ. Criteria for nonsurgical management of subperiosteal abscess of the orbit: analysis of outcomes 1988-1998. Ophthalmology 2000;107(8):1454-6; discussion 7-8.
Fu SY, Su GW, McKinley SH, Yen MT. Cytokine expression in pediatric subperiosteal orbital abscesses. Can J Ophthalmol 2007;42(6):865-9.  
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# Goldstein SM, Shelsta HN. Community-acquired Methicillin-resistant Staphylococcus aureus Periorbital Cellulitis: A Problem Here to Stay. Ophthal Plast Reconstr Surg 2009;25(1):77.
 
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# Harris GJ. Subperiosteal abscess of the orbit: computed tomography and the clinical course. Ophthal Plast Reconstr Surg 1996;12(1):1-8.
Garcia GH, Harris GJ. Criteria for nonsurgical management of subperiosteal abscess of the orbit: analysis of outcomes 1988-1998. Ophthalmology 2000;107(8):1454-6; discussion 7-8.  
+
# McKinley SH, Yen MT, Miller AM, Yen KG. Microbiology of pediatric orbital cellulitis. Am J Ophthalmol 2007;144(4):497-501.
 
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# Miller A, Castanes M, Yen M, et al. Infantile orbital cellulitis. Ophthalmology 2008;115(3):594.
Goldstein SM, Shelsta HN. Community-acquired Methicillin-resistant Staphylococcus aureus Periorbital Cellulitis: A Problem Here to Stay. Ophthal Plast Reconstr Surg 2009;25(1):77.  
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# Nageswaran S, Woods CR, Benjamin DK, Jr., et al. Orbital cellulitis in children. Pediatr Infect Dis J 2006;25(8):695-9.
 
 
Harris GJ. Subperiosteal abscess of the orbit. Age as a factor in the bacteriology and response to treatment. Ophthalmology 1994;101(3):585-95.
 
 
 
Harris GJ. Subperiosteal abscess of the orbit: computed tomography and the clinical course. Ophthal Plast Reconstr Surg 1996;12(1):1-8.  
 
 
 
McKinley SH, Yen MT, Miller AM, Yen KG. Microbiology of pediatric orbital cellulitis. Am J Ophthalmol 2007;144(4):497-501.  
 
 
 
Miller A, Castanes M, Yen M, et al. Infantile orbital cellulitis. Ophthalmology 2008;115(3):594.  
 
 
 
Nageswaran S, Woods CR, Benjamin DK, Jr., et al. Orbital cellulitis in children. Pediatr Infect Dis J 2006;25(8):695-9.
 
{{Article
 
|Authors=Louise.A.Mawn.CMT,
 
|Category=Articles, Oculoplastics/Orbit, Pediatric Ophthalmology/Strabismus
 
}}
 

Latest revision as of 23:03, March 2, 2021


Orbital Cellulitis
8-month old with recent upper respiratory infection and orbital cellulitis. Infection resolved with intravenous antibiotics.
8-month old with recent upper respiratory infection and orbital cellulitis. Infection resolved with intravenous antibiotics.


Disease Entity

Orbital cellulitis is an infection of the soft tissues of the eye socket behind the orbital septum, a thin tissue which divides the eyelid from the eye socket. Infection isolated anterior to the orbital septum is considered to be preseptal cellulitis. Orbital cellulitis most commonly refers to an acute spread of infection into the eye socket from either extension from periorbital structures (most commonly the adjacent ethmoid or frontal sinuses (90%), skin, dacryocystitis, dental infection, intracranial infection), exogenous causes (trauma, foreign bodies, post-surgical), intraorbital infection (endopthalmitis, dacryoadenitis), or from spread through the blood (bacteremia with septic emboli).

Disease

Orbital Cellulitis (ICD-9 #376.01)

Etiology

Orbital cellulitis most commonly occurs when a bacterial infection spreads from the paranasal sinuses into the orbit. In children under the age of 10 years, paranasal sinusitis most often involves the ethmoid sinus which spreads through the thin lamina papyracea of the medial orbital wall into the orbit. It can also occur when an eyelid skin infection, an infection in an adjacent area, or an infection in the blood stream spreads into the orbit. The drainage of the eyelids and sinuses occurs largely through the orbital venous system: more specifically, through the superior and inferior orbital veins that drain into the cavernous sinus. This venous system is devoid of valves and for this reason infection might spread, in preseptal and orbital cellulitis, into the cavernous sinus causing a sight threatening complication such as cavernous sinus thrombosis.

Risk Factors

Risk factors include recent upper respiratory illness, acute or chronic bacterial sinusitis, trauma, ocular or periocular infection, or systemic infection.

General Pathology

Orbital cellulitis can be caused by an extension from periorbital structures (paranasal sinuses, face and eyelids, lacrimal sac, dental structures). Its cause can also be exogenous (trauma, foreign body, surgery), endogenous (bacteremia with septic embolization), or intraorbital (endophthalmitis, dacryoadenitis).[1] The orbital tissues are infiltrated by acute and chronic inflammatory cells and the infectious organisms may be identified on the tissue sections. The organisms are best identified by microbiologic culture. The most common infectious pathogens include gram positive Streptococcal and Staphylococcal species. In a landmark article by Harris et al, it was noted that in children younger than 9 years of age, the infections are typically from one aerobic organism; in children older than 9 years of age and in adults, the infections may be polymicrobial with both aerobic and anaerobic bacteria.[2]

The most common pathogens in orbital cellulitis are gram positive Strep and Staph species. Streptococcal infections are identified on culture by their formation of pairs or chains. Streptococcal pyogenes (Group A Strep) requires blood agar to grow and exhibits clear (beta) hemolysis on blood agar. Streptococcus such as Streptococcus pneumonia produce green (alpha) hemolysis, or partial reduction of red blood cell hemoglobin. Staphylococcal species appear as a cluster arrangement on gram stain. Staphylococcus aureus forms a large yellow colony on rich medium in distinction to Staphylococcus epidermidis which forms white colonies. Gram negative rods can be seen in both orbital cellulitis related to trauma and in neonates and immunosuppressed patients. Anaerobic bacteria such as Peptococcus, Peptostreptococcus, and Bacteroides can be involved in infections extending from sinusitis in adults and older children. Fungal infections with either Mucor or Aspergillus need to be considered in immunocompromised or diabetic patients; immunocompetent patients may also have fungal infections in rare cases.

Pathophysiology

Orbital cellulitis most commonly occurs in the setting of an upper respiratory or sinus infection. The human upper respiratory tract is normally colonized with Strep pneumoniae and infection can occur through several mechanisms. Strep pyogenes infections also occur primarily in the respiratory tract. The complex cell surface of this gram-positive organism determines its virulence and ability to invade the surrounding tissue and incite inflammation. Staph aureus infections occur commonly in the skin and spread to the orbit from the skin. Staphylococcal organisms also produce toxins which help to promote their virulence and leads to the inflammatory response seen in these infections. The inflammatory response elicited by all these pathogens plays a major role in tissue destruction in the orbit.

Primary prevention

Identifying patients and effectively treating upper respiratory or sinus infections before they evolve into orbital cellulitis is an important aspect of preventing preseptal cellulitis from progressing to orbital cellulitis. Equally important in preventing orbital cellulitis is prompt and appropriate treatment of preseptal skin infections as well as infections of the teeth, middle ear, or face before they spread into the orbit.

Diagnosis

The diagnosis of orbital cellulitis is based on clinical examination. The presence of the following signs is suggestive of orbital involvement: proptosis, chemosis, pain with eye movements, ophthalmoplegia, optic nerve involvement as well as fever, leukocytosis (75% of cases), and lethargy. Other signs and symptoms include rhinorrhea, headache, tenderness on palpation, and eyelid edema. Intraocular pressure may be elevated if there is increased venous congestion. In addition to clinical suspicion, diagnostic imaging using computed tomography (CT) may help distinguish between preseptal and orbital cellulitis while also looking for complications of orbital cellulitis (see below).

History

The presence of a painful red eye, with lid edema in a child with a recent upper respiratory infection is the typical presentation of orbital cellulitis. Patient history should also include the presence of headache, orbital pain, double vision, progression of symptoms, recent upper respiratory symptoms (e.g. nasal discharge or stuffiness), pain over sinuses, fever, lethargy, recent periocular trauma or injury, family or health care contacts with Methicillin-resistant Staphylococcus aureus (MRSA), history of sinus, ear, dental, or facial infections or surgery, recent ocular surgery, pertinent medical conditions, medications currently used, as well as the presence of diabetes mellitus and the immune status of the patient. Specific questions regarding any change in vision, mental status, pain with neck movement, or nausea or vomiting should also be asked.

Physical examination

The physical examination should include:

  • Best-corrected visual acuity (BCVA). Decreased vision might be indicative of optic nerve involvement or could be secondary to severe exposure keratopathy or retinal vein occlusion.
  • Color vision assessment to assess the presence of optic nerve involvement.
  • Proptosis measurements using Hertel exophthalmometry.
  • Visual field assessment via confrontation.
  • Assessment of pupillary function with particular attention paid to the presence of a relative afferent pupillary defect (RAPD).
  • Ocular motility and presence of pain with eye movements. Also, there might be involvement of the III, IV, and V1/V2 cranial nerve in cases of cavernous sinus involvement.
  • Orbit exam should include documentation of direction of displacement of globe (e.g. a superior subperiosteal abscess will displace the globe inferiorly), resistance to retropulsion on palpation, unilateral or bilateral involvement (bilateral involvement is virtually diagnostic of cavernous sinus thrombosis[3]).
  • Measurement of intraocular pressure (IOP). Increased venous congestion may result in increased IOP.
  • Slit-lamp biomicroscopy of the anterior segment if possible to look for signs of exposure keratopathy in cases of severe proptosis.
  • Dilated fundus exam will exclude or confirm the presence of optic neuropathy or retinal vascular occlusion.

Signs

As a preseptal infection progresses into the orbit, the inflammatory signs typically increase with increasing redness and swelling of the eyelid with a secondary ptosis. As the infection worsens, proptosis develops and extraocular motility becomes compromised. When the optic nerve is involved, loss of visual acuity is noted and an afferent pupillary defect can be appreciated. The intraocular pressure often increases and the orbit becomes resistant to retropulsion. The skin can feel warm to the touch and pain can be elicited with either touch or eye movements. Examination of the nose and mouth is also warranted in order to look for any black eschar which would suggest a fungal infection. Purulent nasal discharge with hyperemic nasal mucosa may be present.

Symptoms

Systemic symptoms including fever and lethargy may or may not be present. Change in the appearance of the eyelids with redness and swelling is frequently a presenting symptom. Pain, particularly with eye movement, is commonly noted. Double vision may also occur.

Diagnostic procedures

Computed tomography (CT) of the orbit is the imaging modality of choice for patients with orbital cellulitis. Most of the time, CT is readily available and will give the clinician information regarding the presence of sinusitis, subperiosteal abscess, stranding of orbital fat, or intracranial involvement. Nevertheless, in cases of mild to moderate orbital cellulitis with no optic nerve involvement, the initial management of the patient remains medical. Imaging is warranted in children and in cases of poor response to intravenous antibiotics with progression of orbital signs in order to confirm the presence of complications such as subperiosteal abscess or intracranial involvement. Although a magnetic resonance imaging (MRI) scan is safer in children since there is no risk of radiation exposure, the long acquisition time and the need for prolonged sedation make CT scan the imaging modality of choice. However, if there is suspicion of a concomitant cavernous sinus thrombosis, MRI may be a useful adjunct to a CT scan.

Laboratory test

Admission to the hospital is warranted in all cases of orbital cellulitis. A complete blood count with differential, blood cultures, and nasal and throat swabs should be ordered.

Differential Diagnosis

The differential diagnosis includes:

  • Idiopathic inflammation/specific inflammation (e.g. orbital pseudotumor, granulomatosis with polyangiitis, sarcoidosis)
  • Neoplasia (e.g. lymphangioma, hemangioma, leukemia, rhabdomyosarcoma, lymphoma, retinoblastoma, metastatic carcinoma)
  • Trauma (e.g. retrobulbar hemorrhage, orbital emphysema)
  • Systemic diseases (e.g sickle cell disease with bony infarcts and subperiosteal hematomas)
  • Endocrine disorders (e.g. thyroid ophthalmopathy)

Management

General treatment

The management of orbital cellulitis requires admission to the hospital and initiation of broad-spectrum intravenous antibiotics that address the most common pathogens. Blood cultures and nasal/throat swabs should be undertaken, and the antibiotics should be modified based on the results. In infants with orbital cellulitis, a 3rd generation cephalosporin is usually initiated such as cefotaxime, ceftriaxone or ceftazidime along with a penicillinase-resistant penicillin. In older children, since sinusitis is most commonly associated with aerobic and anaerobic organisms, clindamycin might be another option. Metronidazole is also being increasingly used in children. If there is concern for MRSA infection, vancomycin may be added as well.[4] As mentioned before, the antibiotic regimen should be modified based on the results of the cultures if needed. The patient should be followed closely in the hospital setting for progression of orbital signs and development of complications such as cavernous sinus thrombosis or intracranial extension, which can be lethal.[3] Once improvement has been documented with 48 hours of intravenous antibiotics, consideration for switching to oral antibiotics may be appropriate.

Medical follow up

A multi-disciplinary approach is usually warranted for patients with orbital cellulitis under the care of pediatricians, ENT surgeons, ophthalmologists, and infectious disease specialists.

Surgery

The prevalence of subperiosteal or orbital abscess complicating an orbital cellulitis approaches 10%. The clinician should suspect the presence of such an entity if there is progression of orbital signs, and/or systemic compromise despite the initiation of appropriate intravenous antibiotics for at least 24-48 hours. In these cases, a contrast-enhanced CT scan should be ordered to evaluate the orbit, the paranasal sinuses, and/or the brain. If there is associated sinusitis, ENT should be consulted. If an orbital abscess is present it should be drained. The management of subperiosteal abscess remains controversial since there are cases of resolution with the use of intravenous antibiotics only. As a general recommendation (as initially described by Garcia and Harris), observation with intravenous antibiotics only (i.e. no drainage of the subperiosteal abscess) is indicated when:

  • Child is under the age of 9 years
  • No intracranial involvement
  • Medial wall abscess is of moderate or smaller size
  • No vision loss or afferent pupillary defect
  • No frontal sinus involvement
  • No dental abscess

If there is evidence of intracranial extension of the infection, evidence of optic nerve compromise, clinical deterioration despite 48 hours of intravenous antibiotics, suspicion of anaerobic infection (e.g. presence of gas in abscess on CT), or recurrence of subperiosteal abscess after prior drainage, surgery is almost always indicated.[1] At the time of surgery, cultures and susceptibility testing may be obtained from samples to help tailor therapy.

Complications

The complications of orbital cellulitis are ominous and include severe exposure keratopathy with secondary ulcerative keratitis, neutrophic keratitis, secondary glaucoma, septic uveitis or retinitis, exudative retinal detachment, inflammatory or infectious neuritis, optic neuropathy, panophthalmitis, cranial nerve palsies, optic nerve edema, subperiosteal abscess, orbital abscess, central retinal artery occlusion, retinal vein occlusion, blindness, orbital apex syndrome, cavernous sinus thrombosis, meningitis, subdural or brain abscess, and death.

Prognosis

With prompt recognition and aggressive medical and/or surgical treatment, the prognosis is excellent.

Additional Resources

References

  1. 1.0 1.1 Basic and Clinical Science Course 2019-2020: Oculofacial Plastic and Orbital Surgery. San Francisco, CA: American Academy of Ophthalmology; 2019.
  2. Harris GJ. Subperiosteal abscess of the orbit. Age as a factor in the bacteriology and response to treatment. Ophthalmology 1994;101(3):585-95.
  3. 3.0 3.1 Basic and Clinical Science Course 2019-2020: Pediatric Ophthalmology and Strabismus. San Francisco, CA: American Academy of Ophthalmology; 2019.
  4. Liao, S., Durand, M. L., & Cunningham, M. J. (2010). Sinogenic orbital and subperiosteal abscesses: Microbiology and methicillin-resistant Staphylococcus aureus incidence. Otolaryngology–Head and Neck Surgery143(3), 392–396.
  1. Brook I. Role of methicillin-resistant Staphylococcus aureus in head and neck infections. J Laryngol Otol 2009;123(12):1301-7.
  2. Cannon PS, Mc Keag D, Radford R, et al. Our experience using primary oral antibiotics in the management of orbital cellulitis in a tertiary referral centre. Eye (Lond) 2009;23(3):612-5.
  3. Fu SY, Su GW, McKinley SH, Yen MT. Cytokine expression in pediatric subperiosteal orbital abscesses. Can J Ophthalmol 2007;42(6):865-9.
  4. Garcia GH, Harris GJ. Criteria for nonsurgical management of subperiosteal abscess of the orbit: analysis of outcomes 1988-1998. Ophthalmology 2000;107(8):1454-6; discussion 7-8.
  5. Goldstein SM, Shelsta HN. Community-acquired Methicillin-resistant Staphylococcus aureus Periorbital Cellulitis: A Problem Here to Stay. Ophthal Plast Reconstr Surg 2009;25(1):77.
  6. Harris GJ. Subperiosteal abscess of the orbit: computed tomography and the clinical course. Ophthal Plast Reconstr Surg 1996;12(1):1-8.
  7. McKinley SH, Yen MT, Miller AM, Yen KG. Microbiology of pediatric orbital cellulitis. Am J Ophthalmol 2007;144(4):497-501.
  8. Miller A, Castanes M, Yen M, et al. Infantile orbital cellulitis. Ophthalmology 2008;115(3):594.
  9. Nageswaran S, Woods CR, Benjamin DK, Jr., et al. Orbital cellulitis in children. Pediatr Infect Dis J 2006;25(8):695-9.