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 Cellulitis with retrobulbar hematoma and proptosis

1. Swelling and erythema of tissues surrounding the orbit AND:
   1. Proptosis
   2. Chemosis
   3. Globe displacement
   4. Limitation of eye movements
   5. Double vision
   6. Decreased visual acuity

Diagnosis

1. CT Orbit with IV contrast
   1. Findings c/w orbital cellulitis:
      1. Proptosis
      2. Inflammation of ocular muscles
      3. Subperiosteal or orbital abscess

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

Treatment

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

Consults

• Ophthalmology consult to arrange close followup

Disposition

• Admit

Complications

1. Orbital Abscess
   1. Pts tend to have severe proptosis, globe displacement, and appear systemically ill
   2. May be clinically indistinguishable from orbital cellulitis; requires CT
2. Meningitis
3. Cavernous sinus thrombosis
4. Frontal bone osteomyelitis
5. Subdural empyema
6. Epidural abscess
7. Brain abscess

See Also

• Periorbital vs Orbital Cellulitis
• Periorbital Swelling
• Periorbital Cellulitis

Source

• UpToDate
• Tintinalli