Orbital cellulitis is an infection of the soft tissues of the orbit posterior to the orbital septum. Infection may involve all the orbital structures, including extraocular muscles, sensory and motor nerves, and the optic nerve. Patients present with a moderate to severely inflamed painful eye, conjunctival infection, swelling of the eyelids, and chemosis (conjunctival swelling). As infection progresses, swelling increases and the eye becomes more chemotic and proptotic. Eye movement is diminished in some areas of gaze, or in severe cases, all areas of gaze (frozen globe). Patients are usually febrile and appear to be in acute distress. Orbital cellulitis may occur as a progression from preseptal cellulitis (a much more benign condition) or originate from untreated or undertreated infections of deep skin or paranasal sinuses. Causative pathogens include Streptococcus pneumoniae, nontypeable Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus, Streptococcus pyogenes, and anaerobes (Peptostreptococcus, Bacteroides, Fusobacterium) depending on the source of infection. Differential diagnosis includes preseptal cellulitis, idiopathic orbital inflammatory pseudotumor, thyroid orbitopathy, dacryocystitis, dacryoadenitis, and trauma with retrobulbar hemorrhage.
Orbital cellulitis is a true medical emergency particularly in advanced cases when extension posteriorly to the brain can occur and cause rapid deterioration in the patient’s status. Evaluate the orbit and paranasal sinuses with neuroimaging (CT scan with contrast or MRI). Admit patient and obtain prompt ear, nose, throat (ENT); infectious disease; and ophthalmologic consultations in the ED once the diagnosis of orbital cellulitis is considered. If a subperiosteal abscess is noted on imaging, refer promptly to oculoplastic surgery for possible drainage. Begin broad-spectrum intravenous (IV) antibiotics (eg, vancomycin plus either ceftriaxone or piperacillin and tazobactam [Zosyn] or sulbactam and ampicillin [Unasyn]) as soon as possible. Surgical intervention may be needed. If there is an extension posterior to the orbit, admit to ICU.
Figure 8.2 ▪ Orbital Cellulitis.
Severe proptosis, malalignment of globe with restriction of eye movements, swelling of eyelids, and unilateral involvement are characteristic findings of orbital cellulites (photograph taken after drainage of subperiosteal abscess). (Photo contributor: Binita R. Shah, MD.)
Figure 8.3 ▪ Orbital Cellulitis.
Left orbital cellulitis with subperiosteal abscess and extensive ethmoid and maxillary sinusitis are seen in this postcontrast CT scan. About 75% to 90% of cases of orbital cellulitis are associated with either preceding or concurrent acute paranasal sinusitis (commonly involved sinuses: ethmoid, maxillary, and frontal). (Photo contributor: John Amodio, MD.)
Figure 8.4 ▪ Metastatic Neuroblastoma: Differential Diagnosis of Proptosis.
(A, B) An 11-month-old infant with bilateral “raccoon eyes” (periorbital ecchymosis) and orbital proptosis which are common presenting signs of metastatic neuroblastoma (most common tumor to metastasize to orbit in childhood). (C) Aggressive bony erosion and periosteal reaction are seen involving orbits and temporal bone. Bilateral enhancing soft tissue masses in extraconal spaces with epidural enhancing masses, and enhancing mass posterior to right temporal bone is also seen. (Photo contributor: Binita R. Shah, MD.)
Diminished vision can rapidly progress if the orbital process does not respond to treatment; this is a poor prognostic sign.
Orbital cellulitis can be life-threatening if infection spreads to the cavernous sinus.
If sinus infection is the source, ENT evaluation with surgical drainage may be indicated.
Figure 8.5 ▪ Rhabdomyosarcoma: Differential Diagnosis of Proptosis.
A rapidly growing orbital mass in a 7-year-old girl. Rhabdomyosarcoma presents with painless proptosis, globe displacement with edema and erythema of the lids. (B) Postcontrast orbital CT reveals a large enhancing intraconal soft tissue mass posterior to the left globe causing proptosis. (Photo contributor: Binita R. Shah, MD.)
The authors acknowledge the special contributions of Mert Erogul, MD, and Binita R. Shah, MD, to prior edition.
Preseptal cellulitis is infection and inflammation anterior to the orbital septum and confined to periorbital soft tissues and eyelids. The globe and orbital structures posterior to the septum are not infected; thus, pupillary reaction, visual acuity, and ocular motility should not be affected. Sinusitis is the most common cause of preseptal cellulitis; other causes include local skin abrasions, hordeolum, or insect bites. Common pathogens are S pneumoniae, S aureus, S pyogenes, and H influenzae (nonimmunized children). Patients present with eyelid swelling, erythema, tense edema, warmth, and tenderness. Tense edema may cause eye closure and the patient may be unable to open the eye spontaneously. Low-grade fever is often present. Differential diagnosis includes orbital cellulitis, allergic conjunctivitis, contact dermatitis, chalazion/hordeolum, necrotizing fasciitis, viral conjunctivitis with secondary eyelid swelling, idiopathic orbital inflammation, thyroid ophthalmopathy, dacryoadenitis, dacryocystitis, rhabdomyosarcoma, and trauma.
Obtain a complete history, including sinus disease, trauma, recent dental work, or infections. Perform an eye examination, palpating the periorbital area, checking visual acuity, assessing pupils and extraocular movements, and looking for injection and chemosis. Preseptal cellulitis is diagnosed by absence of all of the following findings: decreased visual acuity, pain with eye movement, chemosis or significant conjunctival injection, abnormal pupillary response or afferent papillary defect, proptosis, or diplopia. Any of the aforementioned findings indicate orbital cellulitis.
Order CBC with differential, blood culture, and wound culture as clinically indicated. Consider CT scan of orbits with thin slices (1- to 2-mm cuts) to evaluate for sinus disease, subperiosteal abscess, and consult ophthalmology. Admit children with moderate to severe preseptal cellulitis or patients 1 year for IV antibiotics (eg, ampicillin/sulbactam, ceftriaxone, or vancomycin, if methicillin-resistant S aureus [MRSA] is a possibility]). For patients with mild preseptal cellulitis (not clinically ill), give oral antibiotics (eg, amoxicillin clavulanate [Augmentin] or cefaclor) for 10 days with very close follow-up.
If conjunctivitis is present, recommend warm compresses 3 times a day, bacitracin ophthalmic ointment, or polymyxin-trimethoprim (Polytrim) drops. Incision and drainage may be necessary if an abscess does not improve with antibiotics.
Figure 8.6 ▪ Orbital Anatomy.
Sagittal view of the orbit, illustrating the position of the orbital septum. The orbital septum is an extension of the orbital periosteum to the tarsal plate in both upper and lower eyelids and acts as a physical barrier to preseptal infection, thus preventing spread of infection to the orbital contents. (Reproduced with permission from Smith TF, O’Day D, Wright PF: Clinical implications of preseptal cellulitis in childhood. Pediatrics 1978;62:1007.)
Vesicular rash suggests herpetic periorbital infection.
Close follow-up is mandatory as rarely preseptal cellulitis may progress to orbital cellulites and can be clinically indistinguishable from preseptal cellulitis.
Figure 8.7 ▪ Preseptal Cellulitis.
Intense erythema, eyelid edema, and tenderness due to maxillary sinusitis in an adolescent who had normal vision, full range of eye movements without pain, and absence of proptosis. Preseptal cellulitis is unilateral in the majority. (Photo contributor: Binita R. Shah, MD.)
Figure 8.8 ▪ Orbital Cellulitis; Differential Diagnosis of Preseptal Cellulitis.
Orbital cellulites with proptosis and painful extraocular movements were present in this patient with ethmoid sinusitis and sub periosteal abscess. (Reproduced with permission from Shah BR, Laude TL: Atlas of Pediatric Clinical. WB Saunders, Philadelphia, 2000, p. 155.)
Figure 8.10 ▪ Herpes Simplex Virus (HSV) Infection; Differential Diagnosis of Preseptal Cellulitis.
Multiple grouped vesiculopustular lesions on an erythematous base are seen in HSV infection. Cornea is involved in 10% to 30% of patients with primary ocular HSV infection and patients need urgent evaluation by an ophthalmologist. (Photo contributor: Douglas R. Lazzaro, MD.)
Figure 8.11 ▪ Dacryocystitis; Differential Diagnosis of Preseptal Cellulitis.
Dacryocystocele is swelling of nasolacrimal sac due to fluid accumulation within the sac as a result of punctal and nasolacrimal duct obstruction. If decompression does not occur, dacryocystitis develops. Erythema and swelling are seen in the medial canthal area. Pressure over the lacrimal sac causes severe discomfort and purulent material may be seen at lacrimal puncta. (Photo contributor: Binita R. Shah, MD.)
Chalazion is a result of obstruction and inflammation of the meibomian glands (oil-secreting glands that produce sebum [oil] component of tear film), which are located in the tarsal plate of the eyelids. When these glands become inflamed and obstructed (eg, blepharitis), sebum leaks into surrounding tissue, forming a chalazion filled with lipogranulomatous material. Hordeolum results from acute infection of the sebaceous (stye or external hordeolum) or meibomian glands (internal hordeolum).
Patients present with a visible and palpable circumscribed nodule in the eyelid that is usually solitary but may be bilateral or multiple. Localized edema, erythema, and tenderness may be present, especially when there is a hordeolum. There may be visible “pointing” of mucopurulent discharge or drainage/crusting of skin. Patients may complain of chronic itchy eyes associated with blepharitis or have prior history of chalazion or hordeolum. Differential diagnosis includes preseptal cellulitis or pyogenic granuloma.
Perform an ocular exam including visual acuity and external exam of eyelids and eye, looking for visible signs of discharge or drainage. Edema is usually localized to the lesion. The conjunctiva and sclera are usually uninvolved. Palpation for preauricular lymphadenopathy helps to distinguish viral conjunctivitis (positive node) from other types of conjunctivitis.
Consult ophthalmology if there is significant injection or globe pain. Discharge patients with instructions to start aggressive warm compresses for 15 to 20 minutes, 4 to 6 times a day with light massage of lesion. If discharge or drainage is present, give topical antibiotic ointment such as bacitracin or erythromycin ophthalmic ointment.
Figure 8.13 ▪ Hordeolum.
(A) External hordeolum. An erythematous swelling at lid margin with purulent discharge resulting from infection of the sebaceous glands in the eyelash follicles. (B) Internal hordeolum: infection of the meibomian glands embedded in the tarsal plate. (Photo contributors: Binita R. Shah, MD [A] and Douglas R. Lazzaro, MD [B].)
If there is associated edema and erythema, or systemic symptoms such as fever or chills, give systemic antibiotics with staphylococcal and streptococcal coverage.
Refer patients with chalazion lasting more than 3 weeks for outpatient follow-up with an ophthalmologist.
A hordeolum may cause a preseptal cellulitis or deeper abscess consult ophthalmology when edema, erythema, and pain worsen or if it becomes less localized.
Acute conjunctivitis may be infectious or noninfectious and by definition has a duration of less than 4 weeks. Adenoviral infections are the most common cause of viral conjunctivitis (“pink eye”). Patients present with conjunctival hyperemia, lid edema, serous discharge, foreign body (FB) sensation, and preauricular lymphadenopathy, and often complain of eyelids sticking together (worse in the morning). Acute conjunctivitis may initially present with unilateral symptoms; however, both eyes usually become affected. Consider herpes simplex infection with unilateral conjunctivitis with a vesicular skin rash or crusted lesions on eyelid margin.
Bacterial and viral conjunctivitis can be difficult to distinguish from one another and numerous bacterial pathogens cause conjunctivitis, including S aureus, S pneumoniae, Haemophilus species, or M catarrhalis. A “positive node,” or lymphadenopathy found on preauricular palpation, may help distinguish viral conjunctivitis from other types.
Patients may present with scant discharge or crusting, mild lid edema and injection, or in severe presentations, moderate to severe mucopurulent discharge with significant injection and lid edema. Copious and hyperacute mucopurulent discharge may represent gonococcal conjunctivitis.
Allergic conjunctivitis may present similarly to infectious conjunctivitis but tends to be bilateral and presents with watery discharge, eyelid edema, pruritus, and boggy chemosis.
Differential diagnosis of conjunctivitis includes viral (including herpes simplex [HSV]), bacterial, or allergic conjunctivitis; atopic/vernal conjunctivitis; uveitis; and periorbital cellulitis.
For viral or allergic conjunctivitis, provide instructions for supportive therapy, including cold compresses and preservative free artificial tears for symptomatic relief. Counsel patients that viral conjunctivitis is self-limited; however, it may get worse for the first 4 to 7 days after onset but generally resolves in 2 to 3 weeks (longer if there is corneal involvement). Inquire about anyone in the household with “pink eye” or a recent upper respiratory tract infection. Educate patients on strict hand hygiene as transmission is through contact and patients are contagious for 12 to 14 days. Children with weeping discharge should stay home from school.
If bacterial conjunctivitis is suspected, send discharge for culture, and start topical antibiotic therapy (eg, trimethoprim/polymyxin B 4 times a day or erythromycin ointment thrice daily) for 5 to 7 days. Avoid fluoroquinolone drops in younger children as systemic side effects are possible. If gonococcal conjunctivitis is suspected, send conjunctival swabs for Gram stain and culture, provide systemic therapy (eg, ceftriaxone) and consult ophthalmology to exclude corneal involvement.
For moderate cases of allergic conjunctivitis, consider prescribing olopatadine 0.1% (Patanol) twice a day, or ketotifen 0.025% twice a day. In severe cases, a topical steroid eye drop may be beneficial; however, this should only be prescribed by an ophthalmologist who can monitor for possible side effects.
Check the “ocular vital signs” (red reflex, pupil, visual acuity, and motility) in any child with conjunctivitis.
Ocular pain is usually not associated with allergic, viral, and bacterial conjunctivitis and mandates consultation with ophthalmology.
Globe tenderness, diminished vision, and severe photophobia are all signs of more serious infection and also mandate consultation with ophthalmology.
Photophobia, pseudomembranes or membranes, chemosis, or subconjunctival hemorrhage may indicate epidemic keratoconjunctivitis (EKC), an adenoviral conjunctivitis (sero types 8 and 19) that may involve the cornea. If EKC is suspected, give follow-up with an ophthalmologist.
If HSV infection suspected, consult ophthalmology to exclude corneal involvement (risk of corneal involvement high with lesions on eyelid margin).
Consider sexual abuse (in appropriate setting) if gonococcal conjunctivitis is confirmed by culture.
Figure 8.18 ▪ Bacterial Conjunctivitis.
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