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Orbital Cellulitis

Tal Marom, M.D.

September 2004

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Orbit anatomy

Frontal

Zygoma

Maxillary

NasalEthmoid

Lacrimal

Sphenoid

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Orbital Cellulitis

Orbital cellulitis is a dangerous infection withpotentially serious complications

It is usually caused by a bacterial infection fromthe sinuses (mainly ethmoid, accounting formore than 90% of all cases)

Other causes :a stye on the eyelid, recent trauma

to the eyelid including bug bites, or a foreignobject

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Children

In children, orbital cellulitis is usually from a

sinus infection and due to the organism

Hemophilus influenzae (decrease in incidenceafter vaccination program implentation).

Other organisms are Staphlococcus aureus,

Streptococcus pneumoniae, andBetahemolytic streptococci

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Pathophysiology

extension of infection from the periorbital structures,

most commonly from the paranasal sinuses, but also

from the face, globe, and lacrimal sac direct inoculation of the orbit from trauma or surgery

(orbital decompression, dacryocystorhinostomy,

eyelid surgery, strabismus surgery, retinal surgery,

and intraocular surgery, have been reported as theprecipitating cause of orbital cellulitis)

hematogenous spread from bacteremia

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Orbital septum

The orbit is separated from the soft tissue of the eyelid bythe orbital septum. This is a fascial plane that is continuouswith the periosteum of the facial bones.

The orbital septum inserts into the tarsal plate of the upperand lower eyelids.

The orbital septum usually proves to be an effective barrierthat prevents the spread of infection from the eyelids

posteriorly to the orbit.

While preseptal cellulitis can occasionally spread to theorbital contents, it is generally a clinical entity that isdistinct from orbital cellulitis

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Orbital septum

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Orbital vs. Preseptal Cellulitis

Orbital cellulitis is infection of the soft

tissues of the orbit posterior to the orbital

septum, differentiating it from preseptalcellulitis, which is infection of the soft

tissue of the eyelids and periocular region

anterior to the orbital septum DD: orbital pseudotumor (inflammatory

condition, responds to steroids)

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Chandler Classification

Stage I Inflammatory edema-Preseptal

Stage II Orbital cellulitis - Postseptal

Stage III Subperiostal abscess

Stage IV Orbital abscessStage V Complication due to posterior

extension

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Symptoms

Fever, generally 102 degrees F or greater.

Painful swelling of upper and lower lids (upper is usuallygreater).

Eyelid appears shiny and is red or purple in color.

Infant or child is acutely ill or toxic.

Eye pain especially with movement.

Decreased vision (because the lid is swollen over the eye).

Eye bulging (forward displacement of the eye). Swelling of the eyelids

General malaise.

Restricted or painful eye movements

http://www.nlm.nih.gov/medlineplus/ency/article/003090.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003103.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003032.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003029.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003033.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003089.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003089.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003033.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003029.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003032.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003103.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003090.htm

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Complications

Subperiostal/Orbital abscess (Chandler III-IV)

Cavernous sinus thrombosis

Hearing loss

Septicemia or blood infection

Meningitis Optic nerve damage and blindeness

http://www.nlm.nih.gov/medlineplus/ency/article/001628.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003044.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/001355.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000680.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000680.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/001355.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003044.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/001628.htmhttp://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/oph/images/Large/230_1small.jpg&template=izoom2

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A male with orbital cellulitis with proptosis,

ophthalmoplegia, and edema and erythema of the eyelids

http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/oph/images/Large/230_1small.jpg&template=izoom2

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Non-surgical treatment

IV ABx

Antifungals (if indicated)

Nasal decongestants (open sinus ostia)

DureticsDIAMOX (carbonic anhydrase

inhibitor), mannitol (reduce IOP)

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Surgical Treatment1. Surgical drainage if the response to appropriate antibiotic

therapy is poor within 48-72 hours or if the CT scan showsthe sinuses to be completely opacified.

2. Consider orbital surgery, with or without sinusotomy, inevery case of subperiosteal or intraorbital abscessformation.

3. Surgical drainage of an orbital abscess is indicated if anyof the following occurs: decrease in vision, An afferent

pupillary defect. proptosis progresses despite appropriateantibiotic therapy

4. The size of the abscess does not reduce on CT scan within48-72 hours after appropriate antibiotics have beenadministered.

5. If brain abscesses develop and do not respond to antibiotictherapy, craniotomy is indicated.

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How?

Superior orbit decompression

Medial orbit decompression

Inferior orbit decompression

Lateral orbit decompression

Intranasal approach

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Superior Orbit Decompression

Frontal cranioitomy

unroofing of superior

wall of orbit Titanium sheild placed

to support the frontal

lobe of the brain

High morbidity,

consider only for

severe cases

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Medial Orbit Decompression

External ethmoidectomy incision or coronal

forehead approach

External ethmoidectomy- complete ethmoid sinus

resection, then orbital fat herniates into sinus defect

Coronal incision- ethmoidectomy via a superior

approach, more risk for lacrimal sac and trochlea

injury

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Inferior Orbit Decompression

Orbital floor blow-out fracture , but spares

infraorbital nerve

Subcilliary eyelid incision or Caldwell-Lucincision

Combined approach?

Intraorbital fat herniates maxillary sinus

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Lateral Orbit Decompression

Lateral canthotomy

Removal of lateral orbital bone posterior to the

rim Orbital fat protrudes the newly created space

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An incision extending from the lateral canthus to the

area just below the inferior punctum is created 4 mm to

5 mm below the lower border of the tarsal plate to avoid

injury to the septum and the canaliculus

http://www.ophthalmic.hyperguides.com/tutorials/oculoplastics/surgery/slide1a.asp

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http://www.ophthalmic.hyperguides.com/tutorials/oculoplastics/surgery/slide5H.asp

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Intranasal approach

Decompression of medial anf medioinferior

floors of orbit

Endoscopic sinus surgery technique Anterior Ethmoidectomy

Maxillary antrostomy