Orbital Infections
ORBITAL CELLULITIS
Orbital cellulitis is a real ophthalmic emergency that needs prompt recognition and treatment. In severe cases, the infection can progress rapidly over a few hours with potential life-threatening complications.
Epidemiology and Etiology
• Age: All ages
• Gender: Equal incidence in males and females
• Etiology: Sinusitis is the most common cause, but other causes include skin infections or skin wounds, dental infections, and dacryocystitis.
History
• One to 3 days of progressive swelling around the eye
• The process may be preceded by an upper respiratory infection.
• The patient may have a history of sinus infections.
Examination
• Erythema, swelling, chemosis, restricted motility, pain on eye movement, and proptosis characterize orbital cellulitis.
• These symptoms are progressive over 24 to 48 hours.
• As the infection advances, vision can be affected.
• Patients may or may not have fever and leukocytosis.
• It is very important to make a distinction between the signs of orbital cellulitis and those of preseptal cellulitis where there is just swelling and redness of the eyelids (Fig. 11-1).
Imaging
• Computed tomography (CT) scanning is not required to make the diagnosis of orbital cellulitis but is needed to look for the source of infection (e.g., sinusitis, orbital abscess) and to rule out other processes such as an orbital tumor.
• A CT scan will show sinusitis if present, which may require drainage.
• Orbital foreign bodies or an orbital abscess can require additional surgery.
Special Considerations
• Aggressive and prompt treatment of orbital cellulitis is required to prevent posterior extension of the infection, which can result in cavernous sinus thrombosis, a life-threatening condition.
Differential Diagnosis
• Preseptal cellulitis
• Orbital pseudotumor
• Orbital abscess
• Phycomycosis
• Orbital arteriovenous malformation (fistula)
• Metastatic orbital tumor
 FIGURE 11-1. Preseptal cellulitis. A. Child with a scratch on the lateral left upper eyelid that resulted in preseptal cellulitis 2 days later. Ocular motility is normal. The patient responded to antibiotics within 48 hours. |
Laboratory Tests
• Complete blood count: White count may be normal.
• Blood cultures are of questionable value.
Treatment
• Immediate broad-spectrum IV antibiotics, orbital imaging, and careful monitoring for improvement in the first 24 to 48 hours
Prognosis
• Good. Rare complications occur from development of an abscess or cavernous sinus thrombosis.
 FIGURE 11-1. (continued) B. Early cellulitis related to a subconjunctival abscess that required drainage plus oral and topical antibiotics. C to F. Patient with 2 days of swelling of the right eye with orbital cellulitis. The eye is swollen shut but, with lifting, the eyelid ocular motility is limited and there is chemosis. The patient responded with improvement in 48 hours on IV antibiotics. |
 FIGURE 11-1. (continued) G. Computed tomography scan shows proptosis and sinusitis and is consistent with the clinical diagnosis of orbital cellulitis. |
ORBITAL ABSCESS
An orbital abscess is a rare complication of sinusitis and orbital cellulitis. Orbital cellulitis that does not improve on broad-spectrum IV antibiotics needs careful imaging to look for an orbital abscess.
Epidemiology and Etiology
• Age: Any
• Gender: Equal
• Etiology: Sinus disease is the most common source of a subperiosteal abscess. Rarely, an orbital foreign body can be the cause and must be suspected if the abscess is intraorbital (especially an intraconal abscess).
History
• Orbital cellulitis with no sign of improvement on appropriate antibiotics
• Patients often have a long history of sinus disease.
Examination
• Signs are those of orbital cellulitis that do not improve on appropriate IV antibiotics.
• The globe may be displaced away from the abscess.
• The abscess is diagnosed on orbital imaging (Fig. 11-2).
Imaging
• CT scanning/magnetic resonance imaging (MRI) will demonstrate a subperiosteal opacity usually adjacent to an infected sinus. Rarely, the abscess may be intraconal.
Differential Diagnosis
• Orbital cellulitis
• Phycomycosis
• Cavernous sinus thrombosis
• Orbital pseudotumor
Laboratory Tests
• Complete blood count; culturing of the abscess contents
Treatment
• Most patients will require immediate surgical drainage of the abscess and treatment with broad-spectrum IV antibiotics.
• If significant sinus infection is present, it needs to be treated surgically at the same time.
• Some abscesses have been treated with IV antibiotics alone, and close observation is needed for children younger than 9 years.
Prognosis
• Prompt and aggressive treatment usually allows successful treatment.
• An orbital abscess does have the potential to result in visual loss, motility problems, or even severe central nervous system (CNS) morbidity.
 FIGURE 11-2. Orbital abscess. A. A patient with a 2- to 3-day history of swelling of the left eye. B. There is 5 mm of proptosis and limited motility. |
 FIGURE 11-2. (continued) C. Computed tomography (CT) scan shows pansinusitis with a medial orbital abscess that required surgical drainage.
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