Introduction
- 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
- 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):
- Mucorales (causes mucormycosis) (also affects cases with diabetic ketoacidosis & renal acidosis)
- 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
Other features:
- Eyelid swelling with/without erythema (also found in preseptal cellulitis)
Case studies:
Complications
- Subperiosteal abscess (15-59% cases)
- Orbital abscess (24% cases)
- Vision loss (3-11% cases)
- Extraorbital extension:
- Cavernous sinus thrombophlebitis
- Brain abscess
Pre-antibiotic era outcomes:
- Death (17% cases)
- Permanent blindness (20% cases)
Case study:
Diagnosis
CT scan:
Investigation of choice
- Inflammation of extraocular muscles
- Fat stranding
- Anterior displacement of globe
MRI:
Differential diagnosis:
- Inflammatory causes (thyroid eye disease, idiopathic orbital inflammatory syndrome, sarcoidosis, granulomatosis with polyangiitis)
- Infectious causes (subperiosteal abscess)
- Neoplastic, benign and malignant (dermoid cyst, capillary hemangioma, rhabdomyosarcoma, optic nerve glioma, lymphangioma, neurofibroma, leukemia)
- Trauma (orbital fracture, retrobulbar hemorrhage, orbital foreign body, carotid cavernous fistula)
- Malformation (congenital, vascular)
Management
IV antibiotics:
- Vacnomycin (MRSA coverage) + Ceftriaxone/cefotaxime/ampicillin-sulbactam/piperacillin-tazobactam ± metronidazole (anaerobic coverage)
- In case of allergy to penicillins and/or cephalosporins:
- Vacnomycin (MRSA coverage) + ciprofloxacin/levofloxacin
- Oral antibiotics:
- Clindamycin
- Clindamycin/trimethoprim-sulfamethoxazole + amoxicillin/amoxicillin-clavulanic/cefpodoxime/cefdinir
Surgical management:
- Indications:
- Intracranial extension of the infection
- Poor/failure to respond to antibiotic therapy (confimed in CT after 48 hours)
- Worsening visual acuity/pupillary changes
- Large abscess (> 10 mm)
Summary
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