Orbital cellulitis

Background

Periorbital vs orbital cellulitis

• Orbital cellulitis may mimic periorbital cellulitis early in its course
• Orbital cellulitis
  • Ocular emergency
  • Most often due to ethmoid sinusitis
  • May also be due to orbital trauma, endophthalmitis, infection from teeth / middle ear
  • Not caused by extension of periorbital cellulitis
• Periorbital cellulitis
  • Usually benign
  • Most often due to contiguous infection of soft tissues of face and eyelids

Clinical Features

Orbital Cellulitiswith retrobulbar hematoma and proptosis

Left orbital cellulitis secondary to penetrating dog bite.

• Swelling and erythema of tissues surrounding the orbit AND:
  • Proptosis
  • Chemosis
  • Globe displacement
  • Limitation of EOM
  • Pain with eye movements
  • Double vision
  • Decreased visual acuity
  • Possible CN III, IV, VI palsies in cases of cavernous sinus involvement

Differential Diagnosis

Periorbital swelling

Proptosis

• Normal IOP
  • Orbital cellulitis
  • Orbital pseudotumor
  • Orbital tumor
• Increased IOP
  • Retrobulbar abscess
  • Retrobulbar emphysema
  • Retrobulbar hemorrhage
  • Ocular compartment syndrome
  • Orbital tumor

No proptosis

• Periorbital cellulitis/erysipelas
• Dacryocystitis (lacrimal duct)
• Dacryocele/Dacryocystocele
• Dacryostenosis
• Dacryoadenitis (lacrimal gland)
• Allergic reaction
• Nephrotic Syndrome (pediatrics)

Lid Complications

• Blepharitis (crusts)
• Chalazion (meibomian gland)
• Stye (hordeolum) (eyelash folicle)

Other

• Subperiosteal abscess
• Orbital abscess
• Cavernous sinus thrombosis
• Conjunctivitis
• Contact dermatitis
• Herpes zoster
• Herpes simplex
• Sarcoidosis
• Granulomatosis with polyangiitis

Evaluation

Left medial subperiosteal abscess with associated ethmoid sinusitis.

• CT Orbit with IV contrast

Findings consistent with orbital cellulitis

• Proptosis
• Inflammation of ocular muscles
• Subperiosteal or orbital abscess

Management

Antibiotics

Vancomycin 15-20mg/kg IV BID + (one of the following)

• Ampicillin/Sulbactam 3 g IV q6hr OR
• Ticarcillin/Clavulanate 3.1 g IV q4h OR
• Piperacillin-Tazobactam 4.5 g IV q6h OR
• Ceftriaxone 2 g IV q12hr OR
• Cefotaxime 2 g IV q4h
• Consider fungal infections with mucor or aspergillus in DM or immunocompromised
  • Amphotericin B IV 0.3 mg/kg/day initially
  • May require supplemental intra-orbital catheter delivery

Consults

• Ophthalmology consult to arrange close follow-up

Disposition

• Admit

Complications

• Orbital abscess
  • Patients tend to have severe proptosis, globe displacement, and appear systemically ill
  • May be clinically indistinguishable from orbital cellulitis; requires CT
• Meningitis
• Cavernous sinus thrombosis
• Frontal bone osteomyelitis
• Subdural empyema
• Epidural abscess
• Brain abscess

See Also

• Periorbital Swelling
• Periorbital Cellulitis