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
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
Differential Diagnosis
Proptosis
- Normal IOP
- Orbital cellulitis
- Orbital pseudotumor
- Orbital tumor
- Increased IOP
- Retrobulbar abscess
- Retrobulbar emphysema
- Retrobulbar hemorrhage
- 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
- 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[1]
- 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
References
- Farooq AV et al. Fungal Orbital Cellulitis: Presenting Features, Management and Outcomes at a Referral Center. Orbit. Vol. 34 , Iss. 3,2015.
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