Left post-septal (Chandler II) or orbital cellulitis. Note how the erythema involves the brow, orbit and maxilla. | Last, First. (2019) Periorbital cellulitis — entsho.com. Retrieved April 25, 2019, from https://entsho.com/periorbital-cellulitis
Contents
Introduction
Infective process involving ocular adnexal structures posterior to the orbital septum.
Does not involve the globe itself
M/C cause of unilateral proptosis in children
Aetiology
Infection of the teeth, middle ear, or face
Bacterial rhinosinusitis (M/C cause)
Dacryocystitis
Orbital trauma with fracture/foreign body
Ophthalmic surgery
Such as strabismus surgery, blepharoplasty, radial keratotomy and retinal surgery
Peribulbar anesthesia
Infected mucocele eroding into the orbit
Immunodeficiency
Common bacterial causes:
Staphylococcus aureus
Streptococci
Rare bacterial causes:
Non-spore-forming anaerobes: Aeromonas hydrophila, Pseudomonas aeruginosa, and Eikenella corrodens
Mycobacteria: Mycobacterium tuberculosis
Fungal pathogens (invasive orbital cellulitis) (also common in immunocompromised states):
Aspergillus (cause life-threatening invasive orbital infections) (common in cases with severe neutropenia or other immune deficiencies like HIV)
Clinical features
Ophthalmoplegia with diplopia
Pain with eye movement
Proptosis
Left sided periorbital swelling and proptosis. | Goodyear, P. W. A., Firth, A. L., Strachan, D. R., & Dudley, M. (2004). Periorbital swelling: the important distinction between allergy and infection. Emergency Medicine Journal, 21(2), 240 LP-242. https://doi.org/10.1136/emj.2002.004051
Other features:
Eyelid swelling with/without erythema (also found in preseptal cellulitis)
Case studies:
External photograph of a 10-year-old male child who presented with right eyelid edema, swelling along with proptosis who was found to have evidence of ethmoiditis and maxillary sinusitis along with subperiosteal abscess requiring drainage | Chaudhry, I. A., Al-Rashed, W., & Arat, Y. O. (2012). The hot orbit: orbital cellulitis. Middle East African Journal of Ophthalmology, 19(1), 34–42. https://doi.org/10.4103/0974-9233.92114
A 12-year-old female who presented with left upper eyelid swelling, pain and proptosis of left eye who was found to have evidence of panophthalmitis and superior orbital abscess. Soon after orbital abscess drainage, patient’s upper eyelid swelling and diplopia resolved. Repeat CT-scan revealed evidence of the treated sinusitis as well as orbital abscess. Prior to discharge the patient complained of nausea, vomiting and lethargy. Repeat imaging studies CT-scan and MRI of orbits and brain revealed a sudural empyema and meningitis for which she was treated successfully | Chaudhry, I. A., Al-Rashed, W., & Arat, Y. O. (2012). The hot orbit: orbital cellulitis. Middle East African Journal of Ophthalmology, 19(1), 34–42. https://doi.org/10.4103/0974-9233.92114
A 68-year-old male with diabetes presented with left eyelid swelling, proptosis, and decreased vision. Imaging studies revealed evidence of panendophthalmitis along with orbital cellulitis. Sinus surgery as well as evisceration revealed evidence of fungal infection | Chaudhry, I. A., Al-Rashed, W., & Arat, Y. O. (2012). The hot orbit: orbital cellulitis. Middle East African Journal of Ophthalmology, 19(1), 34–42. https://doi.org/10.4103/0974-9233.92114
Complications
Subperiosteal abscess (15-59% cases)
Orbital abscess (24% cases)
Vision loss (3-11% cases)
Extraorbital extension:
Cavernous sinus thrombophlebitis
Brain abscess
Preseptal and Orbital Cellulitis
Pre-antibiotic era outcomes:
Death (17% cases)
Permanent blindness (20% cases)
Case study:
External photograph of a 21-year-old female who was diagnosed with right-sided orbital abscess which did not undergo drainage. Chronically untreated orbital abscess resulted in erosion of her orbital wall and intracranial extension | Chaudhry, I. A., Al-Rashed, W., & Arat, Y. O. (2012). The hot orbit: orbital cellulitis. Middle East African Journal of Ophthalmology, 19(1), 34–42. https://doi.org/10.4103/0974-9233.92114
Diagnosis
Approach to the evaluation of the swollen red eyelid. (CT = computed tomography; IV = intravenous.) | Carlisle, R. T., & Digiovanni, J. (2015). Differential Diagnosis of the Swollen Red Eyelid. American Family Physician, 92(2), 106–112.
CT scan:
Investigation of choice
Inflammation of extraocular muscles
Fat stranding
Anterior displacement of globe
Computed tomography showing orbital cellulitis (long arrow) and adjacent sinusitis (short arrow). | Carlisle, R. T., & Digiovanni, J. (2015). Differential Diagnosis of the Swollen Red Eyelid. American Family Physician, 92(2), 106–112.
Computed tomography with contrast revealing superior orbital mass displacing globe inferiorily: A) Coronal image, B) axial image. | Adam, R., Gupta, V., & Harvey, J. (2009). Answer: Can you identify this condition? Canadian Family Physician, 55(11), 1100 LP-1101. Retrieved from http://www.cfp.ca/content/55/11/1100.abstract
A, Coronal computed tomographic scan of a 51-year-old, otherwise healthy man shows dacryocystitis before orbital cellulitis and abscess formation. Note the proximity of the lacrimal sac to the intraconal space. B, Coronal computed tomographic scan shows progression to orbital abscess (arrow), indenting the globe. | Kikkawa, D. O., Heinz, G. W., Martin, R. T., Nunery, W. N., & Eiseman, A. S. (2002). Orbital Cellulitis and Abscess Secondary to Dacryocystitis. Archives of Ophthalmology, 120(8), 1096–1099. Retrieved from https://doi.org/
CT scan showing the orbit with the optic nerve (a), compressed by the orbital abscess (b). Proptosis and soft tissue swelling (c) is also shown. | Goodyear, P. W. A., Firth, A. L., Strachan, D. R., & Dudley, M. (2004). Periorbital swelling: the important distinction between allergy and infection. Emergency Medicine Journal, 21(2), 240 LP-242. https://doi.org/10.1136/emj.2002.004051
MRI:
Orbital cellulitis related to mucormycosis (A–C) and bacterial infection (D–F). A, Axial T1-weighted fat-suppressed postcontrast image shows an opacified right maxillary sinus and extensive enhancement throughout the infratemporal fossa tissues, involving the pterygoid muscles (arrow). B, Axial exponential ADC image shows low intensity throughout these tissues (arrow), indicating relatively increased ADC, best appreciated by comparison with the contralateral side. The area of restricted diffusion behind the right maxillary sinus represents abscess. C, Axial exponential ADC image through the orbit shows restricted diffusion within the infarcted posterior right optic nerve (arrow). D, Axial T1-weighted fat-suppressed postcontrast image shows intense enhancement within the periorbital soft tissue (arrow). E, Axial T2-weighted image shows moderate hyperintensity relative to extraocular muscle. F, Axial exponential ADC image slightly lower shows increased ADC throughout the region of nonspecific enhancement (arrow). Restricted diffusion is seen within an abscess (a), which corresponds with a nonenhancing T1 hypointense area. Diffusion is not restricted within the tissues immediately surrounding the focal abscess. G, Axial T1-weighted fat-suppressed postcontrast image shows no enhancement within an abscess (a), with marked enhancement in the area of cellulitis. | Kapur, R., Sepahdari, A. R., Mafee, M. F., Putterman, A. M., Aakalu, V., Wendel, L. J. A., & Setabutr, P. (2009). MR Imaging of Orbital Inflammatory Syndrome, Orbital Cellulitis, and Orbital Lymphoid Lesions: The Role of Diffusion-Weighted Imaging. American Journal of Neuroradiology, 30(1), 64 LP-70. https://doi.org/10.3174/ajnr.A1315
Differential diagnosis:
Inflammatory causes (thyroid eye disease, idiopathic orbital inflammatory syndrome, sarcoidosis, granulomatosis with polyangiitis)
(A) Anatomy of orbit and eyelid with associated pathologic processes by location. (B) External anatomy of the eyelid. | Carlisle, R. T., & Digiovanni, J. (2015). Differential Diagnosis of the Swollen Red Eyelid. American Family Physician, 92(2), 106–112.
Poor/failure to respond to antibiotic therapy (confimed in CT after 48 hours)
Worsening visual acuity/pupillary changes
Large abscess (> 10 mm)
External photograph of a 27-year-old female patient who presented with left periocular edema, pain and decreased vision after a fall several days earlier. Imaging studies confirmed evidence of sinusitis and orbital fracture. Ultrasonography of her left eye revealed a stretched optic nerve along with compression on the eye. During exploration, an abscess was drained from the left lower eyelid that was connected to her maxillary sinus | Chaudhry, I. A., Al-Rashed, W., & Arat, Y. O. (2012). The hot orbit: orbital cellulitis. Middle East African Journal of Ophthalmology, 19(1), 34–42. https://doi.org/10.4103/0974-9233.92114
