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Cellulitis, Orbital
Robert Thomas Carlisle, MD, MPH
image BASICS
DESCRIPTION
  • Acute, severe, vision-threatening infection of orbital contents posterior to orbital septum. Preseptal (previously referred to as periorbital) cellulitis is anterior to the septum. Distinguishing location determines the appropriate workup and treatment (1).
  • Synonym(s): postseptal cellulitis
EPIDEMIOLOGY
  • No difference in frequency between genders in adults
  • More common in children; mean age of surgical cases: 10.1 years; medical pediatric cases: 6.1 years
  • Much less common than preseptal cellulitis
Incidence
Orbital cellulitis has declined since Haemophilus influenzae type b (Hib) vaccine was introduced in 1985. In 2000, incidence per 100,000 in California was 3.5 in whites, 6.1 in blacks, and 3.2 in Hispanics, compared to 6.5 in whites, 10.2 in blacks, and 5.5 in Hispanics in 1990.
ETIOLOGY AND PATHOPHYSIOLOGY
  • Sinusitis is a major risk factor.
  • The ethmoid sinus is separated from the orbit by the lamina papyracea (“layer of paper”), a thin bony separation, and is often the source of contiguous spread of infection to the orbit.
  • The orbital septum is a connective tissue barrier that extends from the skull into the lid and separates the preseptal from the orbital space.
  • Cellulitis in the closed bony orbit causes proptosis, globe displacement, orbital apex syndrome (mass effect on the cranial nerves), optic nerve compression, and vision loss.
  • Orbital abscess (medial wall most common), meningitis, and cavernous sinus thrombosis may occur.
  • Blood cultures are often negative.
  • Cultures of surgical specimens in adults often grow multiple organisms, but >1/3 of cases have no pathogen recovered (2)[B].
  • Most common organisms (3,4)[C]:
    • Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus anginosus
  • Less common organisms:
    • Moraxella catarrhalis, H. influenzae, group A β-hemolytic Streptococcus, Pseudomonas aeruginosa, anaerobes, phycomycosis (mucormycosis), aspergillosis, Mycobacterium tuberculosis, Mycobacterium avium complex, trichinosis, Echinococcus
  • Hib was the most common organism prior to Hib vaccine, Since routine Hib vaccination in 1992, Haemophilus is no longer the leading cause of orbital cellulitis (3,4)[B].
Genetics
No known genetic predisposition
RISK FACTORS
  • Sinusitis is present in 80-90% of cases (3)[C].
  • Orbital trauma, retained orbital FB, ophthalmic surgery
  • Dental, periorbital, skin, or intracranial infection; acute dacryocystitis and acute dacryoadenitis
  • Immunosuppressed patients at increased of adverse outcomes
GENERAL PREVENTION
  • Routine Hib vaccination
  • Appropriate treatment of bacterial sinusitis
  • Proper wound care and perioperative monitoring of orbital surgery and trauma
  • Avoid trauma to the sinus passages.
  • High index of suspicion in febrile patients presenting with eyelid and conjunctival pain, swelling, and erythema.
COMMONLY ASSOCIATED CONDITIONS
  • >80% cases have contiguous sinusitis.
  • Trauma and intraorbital FB
  • Preseptal cellulitis
  • Adverse outcomes of orbital apex syndrome, vision loss, ophthalmoplegia, abscess, meningitis, or cavernous sinus thrombosis
image DIAGNOSIS
PHYSICAL EXAM
  • Vital signs
    • Assess visual acuity (with glasses if required).
    • Lid exam and palpation of the orbit
    • Pupillary reflex for afferent pupillary defect
    • Extraocular movements; assess for pain with eye movement—if present, concerning for orbital cellulitis.
    • Red desaturation: Patient views red object with one eye and compares to the other; reduced red color may indicate optic nerve involvement.
    • Confrontation visual field testing
DIFFERENTIAL DIAGNOSIS
  • Preseptal cellulitis
    • Eyelid erythema with or without conjunctival erythema, afebrile, no pain on eye movement, no diplopia, normal eye exam, vision intact (5)[C]
  • Metastatic tumors and autoimmune inflammation may masquerade as orbital cellulitis in rare cases. Usually present with painless slow onset of symptoms
  • Idiopathic orbital inflammatory disease (orbital pseudotumor) (3)[C]
    • Afebrile, normal WBCs; usually subacute, may have pain, responds to steroids
  • Orbital FB
  • Arteriovenous fistula (carotid-cavernous fistula)
    • Spontaneous or due to trauma; bruit may be present. Insidious, subacute onset
  • Cavernous sinus thrombosis
    • Signs of orbital cellulitis with cranial nerves III, IV, V, and VI findings; often bilateral and acute
    • Severely ill
  • Acute thyroid orbitopathy
    • Afebrile; possible signs of thyroid disease
    • Bilateral orbital involvement
  • Orbital tumor
    • Acute rhabdomyosarcoma in children; acute lymphoblastic leukemia, or metastatic
    • Unilateral
    • Slow onset
  • Trauma, insect bite, ruptured dermoid cyst (6)
  • Clinical signs help distinguish preseptal from orbital cellulitis. Preseptal infection causes erythema, induration, and tenderness of the eyelid and/or periorbital tissues, and patients rarely show signs of systemic illness. Local skin trauma, lacerations, or bug bites can be seen. Extraocular movements and visual acuity are intact.
  • Orbital cellulitis also presents with complaints of a red, swollen, painful eye or eyelid. It also results in proptosis, conjunctival edema, ophthalmoplegia (diminished ocular movement), or decreased visual acuity (7)[C].
  • Staging in cases resulting from acute sinusitis (3)[A]
    • Stage I: no abscess
    • Stage IIa, b, c: small, large, or extending medial subperiosteal abscess
    • Stage III: orbital abscess
  • Chandler staging: (6)[C]
    • Stage I: periorbital cellulitis (considered different entity)
    • Stage II: orbital lining edema, chemosis, proptosis, limitation of extraocular movement, fever
    • Stage III: includes stage II with subperiosteal abscess and occasional vision loss
    • Stage IV: orbital abscess, ophthalmoplegia with vision loss
    • Stage V: extension to cavernous sinus, subdural space, meninges, or brain (3,7)
DIAGNOSTIC TESTS & INTERPRETATION
  • CBC with differential, C-reactive protein, ESR
  • Cultures of eye secretions or nasopharyngeal aspirates are often contaminated by normal flora but may identify causative organism(s).
  • Cultures from orbital and sinus abscesses more often yield positive results but should be limited
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    to cases where invasive procedures are indicated. Cultures from sinus aspirates and abscesses may grow multiple organisms.
  • Blood cultures (often negative) should be obtained prior to initiation of antibiotic therapy.
Initial Tests (lab, imaging)
  • CT scan of orbits and sinuses with axial and coronal views, with and without contrast, is the diagnostic modality of choice (8)[C]. US and MRI are alternatives (9)[B].
    • Thin section (2 mm) CT, coronal and axial views with bone windows to differentiate preseptal from orbital cellulitis, confirm extension into orbit, detect coexisting sinus disease, and identify orbital or subperiosteal abscesses that may require surgery.
    • Deviation of medial rectus indicates intraorbital involvement.
  • MRI offers superior soft tissue resolution for identification of cavernous sinus thrombosis but is less effective for bone imaging.
  • US is used to rule out orbital myositis, locate FBs or abscesses, and follow progression of drained abscess.
Follow-Up Tests & Special Considerations
  • Consider a full-septic evaluation (including LP) before antibiotics in toxic patients or if meningitis is suspected (6)[C].
  • Frequent eye exam and vital signs (q4h) are essential for timely treatment of associated conditions, such as meningitis or orbital abscess.
Diagnostic Procedures/Other
Consult ophthalmology for slit lamp and dilated funduscopic exam; exophthalmometry measurement for proptosis, color vision, automated visual field; and need for surgery.
image TREATMENT
Admit patients with orbital cellulitis for monitoring of ocular status and treatment with broad-spectrum antibiotics (2).
MEDICATION
  • Empiric antibiotic therapy to cover pathogens associated with acute sinusitis (S. pneumoniae, H. influenzae, M. catarrhalis, Streptococcus pyogenes), as well as for S. aureus, S. anginosus, and anaerobes
  • Modify IV antibiotic treatment when sensitivities are available. Duration of IV therapy is usually a week, with additional PO therapy depending on response.
  • PO antibiotic therapy for 2 to 3 weeks or longer (3 to 6 weeks) is recommended for patients with severe sinusitis and bony destruction.
First Line
  • Ampicillin/sulbactam (Unasyn) or ceftriaxone plus metronidazole or clindamycin if anaerobic infection is suspected (2)
    • Ampicillin/sulbactam: 3 g IV q6h for adult; 200 to 300 mg/kg/day divided q6h for children
    • Ceftriaxone: 1 to 2 g IV q12h for adults or 100 mg/kg/day divided BID in children with max 4 g/day
    • Clindamycin: 600 mg IV q8h for adults; 20 to 40 mg/kg/day IV q6-8h for children (10)
    • Metronidazole: 500 mg IV q8 h for adult; 30 to 35 mg/kg/day divided q8h for children
  • ALERT: In severe orbital cellulitis and in suspected or culture-proven MRSA infection, vancomycin remains the parenteral drug of choice. Use in conjunction with agents to cover gram-negative bacteria.
    • Vancomycin: 1 g IV q12h for adults; 40 mg/kg/day IV divided q8-12h, max daily dose 2 g for children (2)
ADDITIONAL THERAPIES
  • Steroid use is controversial (3)[C].
  • PO steroids as an adjunct to IV antibiotics for orbital cellulitis may speed resolution of inflammation (11)[C].
  • Topical erythromycin or nonmedicated ophthalmic ointment protects the eye from exposure in cases with severe proptosis.
  • PO antibiotics for ≥2 weeks are traditionally recommended following IV treatment.
  • Children may be treated with amoxicillin/clavulanate 20 to 40 mg/kg/day divided TID or in adults 250 to 500 mg TID.
ISSUES FOR REFERRAL
Always admit to the hospital and consult with ophthalmology. Consider consultation with ID and ENT for orbital cellulitis; neurology/neurosurgery if intracranial spread is suspected
SURGERY/OTHER PROCEDURES
  • IV antibiotic therapy is the initial therapy.
  • Surgical intervention warranted for visual loss, complete ophthalmoplegia, or well-defined large abscess (>10 mm) on presentation or no clinical improvement after 24 to 48 hours of antibiotic therapy
  • Trauma cases may need débridement or FB removal.
  • Orbital abscess may need surgical drainage.
  • Surgical drainage with 4 to 8 weeks of antibiotics is the treatment of choice for brain abscess.
  • Surgical interventions may include external ethmoidectomy, endoscopic ethmoidectomy, uncinectomy, antrostomy, and subperiosteal drainage.
INPATIENT CONSIDERATIONS
Patients with orbital cellulitis should be admitted for IV antibiotics and serial eye exams to evaluate progression of infection or involvement of optic nerve.
  • Follow temperature, WBC, visual acuity, pupillary reflex, ocular motility, and proptosis.
  • Repeat CT scan, or surgical intervention, may be required for worsening orbital cellulitis cases.
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
Serial visual acuity testing and slit lamp exams
PATIENT EDUCATION
  • Maintain proper hand washing and good skin hygiene.
  • Avoid skin or lid trauma.
REFERENCES
1. Pasternak A, Irish B. Ophthalmologic infections in primary care. Clin Fam Pract. 2004;6(1):19-33.
2. Seltz LB, Smith J, Durairaj VD, et al. Microbiology and antibiotic management of orbital cellulitis. Pediatrics. 2011;127(3):e566-e572.
3. Chadha NK. An evidence-based staging system for orbital infections from acute rhinosinusitis. Laryngoscope. 2012;122(Suppl 4):S95-S96.
4. Hauser A, Fogarasi S. Periorbital and orbital cellulitis. Pediatr Rev. 2010;31(6):242-249.
5. Carlisle RT, Digiovanni J. Differential diagnosis of the swollen red eyelid. Am Fam Physician. 2015;92(2):106-112.
6. Kloek CE, Rubin PA. Role of inflammation in orbital cellulitis. Int Ophthalmol Clin. 2006;46(2):57-68.
7. Distinguishing periorbital from orbital cellulitis. Am Fam Physician. 2003;67(6):1349-1353.
8. Mahalingam-Dhingra A, Lander L, Preciado DA, et al. Orbital and periorbital infections: a national perspective. Arch Otolaryngol Head Neck Surg. 2011;137(8):769-773.
9. Rudloe TF, Harper MB, Prabhu SP, et al. Acute periorbital infections: who needs emergent imaging? Pediatrics. 2010;125(4):e719-e726.
10. Bedwell J, Bauman NM. Management of pediatric orbital cellulitis and abscess. Curr Opin Otolaryngol Head Neck Surg. 2011;19(6):467-473.
11. Pushker N, Tejwani LK, Bajaj MS, et al. Role of oral corticosteroids in orbital cellulitis. Am J Ophthalmol. 2013;156(1):178.e1-183.e1.
Codes
ICD10
  • H05.019 Cellulitis of unspecified orbit
  • H05.011 Cellulitis of right orbit
  • H05.012 Cellulitis of left orbit
Clinical Pearls
  • Most orbital cellulitis cases result from sinusitis.
  • MRSA orbital cellulitis may present without associated upper respiratory infection.
  • CT of orbits and sinuses with axial and coronal views with and without contrast is diagnostic modality of choice for suspected cases of orbital cellulitis.
  • Patients with orbital cellulitis should be admitted for visual monitoring and IV antibiotic therapy.
  • Older age (>10 years) and diplopia may predict need for surgical intervention in children.
  • Ophthalmoplegia, mental status changes, contralateral cranial nerve palsy, or bilateral orbital cellulitis raise suspicion for intracranial involvement.