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Ophthalmology. 2007 Feb;114(2):345-54.

Outcome of treated orbital cellulitis in a tertiary eye care center in the middle East.
Chaudhry IA, Shamsi FA, Elzaridi E, Al-Rashed W, Al-Amri A, Al-Anezi F, Arat YO, Holck DE.

Oculoplastic and Orbit Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia.

PURPOSE: To describe risk factors predisposing patients to orbital cellulitis and potential complications in patients treated at a tertiary eye care referral center in the Middle East. DESIGN: Noncomparative, interventional, retrospective case series. PARTICIPANTS: Patients diagnosed with orbital cellulitis. METHODS: A 15-year clinical review of patients with a diagnosis of orbital cellulitis referred to King Khaled Eye Specialist Hospital, an accredited (Joint Council on Accreditation of Healthcare Organizations, Washington, DC) tertiary care center in Riyadh, Saudi Arabia, was performed. Only those patients who had clinical signs and symptoms or radiologic evidence suggestive of orbital cellulitis were included in the study. MAIN OUTCOME MEASURES: Patient demographics, factors predisposing to orbital cellulitis, and resulting complications. RESULTS:

A total of 218 patients (136 male, 82 female) fulfilling the diagnostic criteria for orbital cellulitis were identified. The average age of these patients was 25.7 years (range, 1 month-85 years). On imaging studies, there was evidence of inflammatory or infective changes to orbital structures; orbital abscesses were identified in 116 patients (53%). Sinus disease was the most common predisposing cause in 86 patients (39.4%), followed by trauma in 43 patients (19.7%). All patients received systemic antibiotic treatment before the identification of any responsible organisms. Of the 116 patients with orbital abscess, 101 patients (87%) required drainage. The results of cultures in patients in whom an orbital abscess was drained were positive for 91 patients (90%). The most common microorganisms isolated from the drained abscesses were Staphylococci and Streptococci species. Blood cultures were positive in only 4 patients from whom blood was drawn for cultures. Visual acuity improved in 34 eyes (16.1%) and worsened in 13 eyes (6.2%), including 9 (4.3%) eyes that sustained complete loss of vision, which was attributed to the delay in correct diagnosis and timely intervention (average 28 days vs. 9 days in patients with no loss of vision; P<0.05). There were 9 cases of intracranial extension of orbital abscesses that required either extended treatment with systemic antibiotics alone or in combination with neurosurgical intervention. Most patients received oral antibiotics on discharge for varying periods. There were 6 cases (2.7%) of strabismus and 4 cases (1.8%) of ptosis that persisted after treatment and resolution of orbital cellulitis. CONCLUSIONS: Untreated sinusitis and prior history of orbital trauma were the 2 major causes of orbital cellulitis in patients referred to a tertiary care eye center in the Middle East. Although rare, severe visual loss still remains a serious complication of delayed detection and intervention in most cases of orbital cellulitis. PMID: 17270683 [PubMed - indexed for MEDLINE]

Am J Ophthalmol. 2007 Oct;144(4):497-501. Epub 2007 Aug 15.

Microbiology of pediatric orbital cellulitis.
McKinley SH, Yen MT, Miller AM, Yen KG.

Cullen Eye Institute, Department of Ophthalmology, Baylor College of Medicine, Houston, Texas, USA.

PURPOSE: To evaluate the microbiology of pediatric orbital cellulitis associated with sinusitis. DESIGN: Retrospective review of medical records of pediatric patients treated for orbital cellulitis. METHODS: All pediatric patients treated for orbital cellulitis associated with sinusitis at Texas Children's Hospital between December 1, 2001 and September 30, 2005 were reviewed. Data collected included patient age, history, microbiology results, and surgical intervention. RESULTS: Thirty-eight cases were identified. Fifteen cases required medical management, whereas 23 patients received a combination of medical and surgical intervention. Three patients had multiple surgical procedures performed. Of the procedures performed, four were sinus irrigation, 12 were sinusotomy and drainage, nine were orbitotomy with drainage of abscess, and one was craniotomy with drainage of abscess. Surgical aspirate specimens yielded a higher positive culture result rate with 9/9 of orbital abscesses and 13/16 of sinus aspirates demonstrating a positive yield. Two of the 27 blood cultures had a positive yield. Staphylococcus species was the most common organism isolated. Methicillin-resistant S. aureus (MRSA) represented 73% of S. aureus isolates. Streptococcus species was the next most common pathogen. Three cultures yielded Haemophilus species with one being positive for H. influenzae. CONCLUSIONS:

Organisms responsible for causing pediatric orbital cellulitis are evolving, with Staphylococcus followed by Streptococcus species being the most common pathogens. The occurrence of MRSA in pediatric orbital cellulitis is increasing, and empiric antimicrobial therapy should be directed against these organisms if they are prevalent in the community. Sinus and orbital abscess aspirates yielded the greatest number of positive cultures, though these invasive surgical procedures should be performed only when clinically indicated. PMID: 17698020 [PubMed - indexed for MEDLINE]

Periorbital cellulitis
From Wikipedia, the free encyclopedia

Periorbital cellulitis caused by a dental infection (also causing maxillary sinusitis) ICD-10 ICD-9 DiseasesDB MedlinePlus eMedicine H05.0, L01.1 373.13 31304 000976 emerg/415 oph/206

Periorbital cellulitis, also known as preseptal cellulitis (and not to be confused with orbital cellulitis, which is behind the septum), is an inflammation and infection of the eyelid and portions of skin around the eye,[1] anterior to the orbital septum. It may be caused by breaks in the skin around the eye, and subsequent spread to the eyelid; infection of the sinuses around the nose (sinusitis); or from spread of an infection elsewhere through the blood.

Signs and symptoms
Periorbital cellulitis must be differentiated from orbital cellulitis, which is an emergency and requires intravenous (IV) antibiotics. In contrast to orbital cellulitis, patients with periorbital cellulitis do not have bulging of the eye (proptosis), limited eye movement (ophthalmoplegia), pain on eye movement, or loss of vision. If any of these features is present, one must assume that the patient has orbital cellulitis and begin treatment with IV antibiotics. CT scan may be done to delineate the extension of the infection. It can be caused by sleeping overnight with make-up on the eyes. This can lead to microscopic pieces of make-up in the eyelid for days causing infection. Affected individuals may experience the following; swelling, redness, discharge, pain, shut eye, conjunctival injection, fever (mild), slightly blurred vision, teary eyes, and some reduction in vision. Typical signs include periorbital erythema, induration, tenderness and warmth.[2]

Staphylococcus and streptococcus bacteria are commonly implicated. The advent of the Haemophilus influenzae vaccine has dramatically decreased the incidence.[3] Spider or other insect bites can also be causal.

Antibiotics are aimed at gram positive bacteria. Cephalexin, dicloxacillin and clindamycin are common choices. Warm to hot compresses help with pain and inflammation. Antibiotic eye drops keep eye moist and prevent infection to eye or other areas. A lubricant, such as petroleum jelly applied with clean cotton swab, provides relief to dry skin on eyelid due to wiping and fevered skin, as well as making it easier to wipe off drainage and/or prevent crusting. Definitely seek medical attention if symptoms persist beyond 2–3 days.

1. ^ althatoz/Atoz/ency/orbital_and_periorbital_cellulitis.jsp 2. ^ Givner LB. Periorbital versus orbital cellulitis. Pediatr Infect Dis J. 2002 Dec;21(12):1157-8 3. ^ Donahue S, Schwartz G (1998). "Preseptal and orbital cellulitis in childhood. A changing microbiologic spectrum". Ophthalmology 105 (10): 1902–5; discussion 1905–6. doi:10.1016/S0161-6420(98)91038-7. PMID 9787362.

Preseptal and Orbital Cellulitis Preseptal cellulitis (periorbital cellulitis) is infection of the eyelid and surrounding skin anterior to the orbital septum. Orbital cellulitis (postseptal cellulitis) is infection of the orbital tissues posterior to the orbital septum. Either can be caused by an external focus of infection (eg, a wound), infection that extends from the nasal sinuses or teeth, or metastatic spread from infection elsewhere. Symptoms include eyelid pain, discoloration, and swelling; orbital cellulitis also causes fever, malaise, proptosis, impaired ocular movement, and impaired vision. Diagnosis is based on history, examination, and CT or MRI. Treatment is with antibiotics and sometimes surgical drainage. Preseptal cellulitis and orbital cellulitis are 2 distinct diseases that share a few clinical symptoms and signs. Preseptal cellulitis usually begins superficial to the orbital septum. Orbital cellulitis usually begins deep to the orbital septum. Both are more common among children; preseptal cellulitis is far more common than orbital cellulitis. Etiology Preseptal cellulitis is caused by contiguous spread of infection from local facial or eyelid injuries, insect or animal bites, conjunctivitis, chalazion, or sinusitis. Orbital cellulitis is most often caused by extension of infection from adjacent sinuses, especially the ethmoid sinus (75 to 90%); it is less commonly caused by direct infection accompanying local trauma (eg, insect or animal bite, penetrating eyelid injuries) or contiguous spread of infection from the face or teeth or by hematogenous spread. Pathogens vary by etiology and patient age. Streptococcus pneumoniae is the most frequent pathogen associated with sinus infection, whereas Staphylococcus aureus and Streptococcus pyogenes predominate when infection arises from local trauma. Haemophilus influenzae type b, once a common cause, is now less common because of widespread vaccination. Fungi are uncommon pathogens, causing orbital cellulitis in diabetic or immunosuppressed patients. Infection in children < 9 yr is typically with a single aerobic organism; patients > 15 yr typically have polymicrobial mixed aerobic and anaerobic (Bacteroides, Peptostreptococcus) infections. Pathophysiology

Because orbital cellulitis originates from large adjacent foci of fulminant infection (eg, sinusitis) separated by only a thin bone barrier, orbital infection can be extensive and severe. Subperiosteal fluid collections, some quite large, can accumulate; they are called subperiosteal abscesses, but many are sterile initially. Fig. 1 Orbital Cellulitis and Its Complications

Complications include vision loss (3 to 11%) due to ischemic retinopathy and optic neuropathy caused by increased intraorbital pressure; restricted ocular movements (ophthalmoplegia) caused by soft-tissue inflammation; and intracranial sequelae from central spread of infection, including cavernous sinus thrombosis, meningitis, and cerebral abscess. Symptoms and Signs Symptoms and signs of preseptal cellulitis include tenderness, swelling, warmth, and redness or discoloration (violaceous in the case of H. influenzae) of the eyelid. Patients may be unable to open their

eyes because of swelling, but visual acuity is not affected.

Symptoms and signs of orbital cellulitis include swelling and redness of the eyelid and surrounding soft tissues, conjunctival hyperemia and chemosis, decreased ocular motility, pain with eye movements, decreased visual acuity, and proptosis caused by orbital swelling. Signs of the primary infection are also often present (eg, nasal discharge and bleeding with sinusitis, periodontal pain and swelling with abscess). Fever, malaise, and headache should raise suspicion of associated meningitis. Some or all of these findings may be absent early in the course of the infection. Subperiosteal abscesses, if large enough, can contribute to symptoms of orbital cellulitis such as swelling and redness of the eyelid, decreased ocular motility, proptosis, and decreased visual acuity. Diagnosis
 

Mainly clinical evaluation CT or MRI if orbital cellulitis is possible

Diagnosis is suspected clinically. Other disorders to consider include trauma, insect or animal bites without cellulitis, retained foreign bodies, allergic reactions, tumors, and inflammatory orbital pseudotumor. Eyelid swelling may require the use of lid retractors for evaluation of the globe, and initial signs of complicated infection may be subtle. An ophthalmologist should be consulted when orbital cellulitis is

suspected. Preseptal cellulitis and orbital cellulitis are often distinguishable clinically. Preseptal cellulitis is likely if eye findings are normal except for eyelid swelling. The presence of a local nidus of infection on the skin makes preseptal cellulitis even more likely. If findings are equivocal, if the examination is difficult (as in young children), or if nasal discharge is present (suggesting sinusitis), CT or MRI should be done to confirm orbital cellulitis, to exclude tumor and pseudotumor, and to diagnose sinusitis if present. MRI is better than CT if cavernous sinus thrombosis is being considered. The direction of proptosis may be a clue to the site of infection; eg, extension from the frontal sinus pushes the globe down and out, and extension from the ethmoid sinus pushes the globe laterally and out. Blood cultures are often done (ideally before beginning antibiotics) in patients with orbital cellulitis but are positive in less than one third. Lumbar puncture is done if meningitis is suspected. Cultures of the paranasal sinus fluid are done if sinusitis is the suspected source. Other laboratory tests are not particularly helpful. Treatment


Preseptal cellulitis: Initial therapy should be directed against sinusitis pathogens (S. pneumoniae, nontypable H. influenzae, S. aureus, Moraxella catarrhalis); however, in areas where methicillin-resistant S. aureus is prevalent, clinicians should add appropriate antibiotics (eg, clindamycin











for inpatient treatment). In patients with dirty wounds, gram-negative

infection must be considered. Outpatient treatment is an option if orbital cellulitis has been definitively excluded; children should have no signs of systemic infection and should be in the care of responsible parents or guardians. Patients should be closely followed by an ophthalmologist. Outpatient treatment options include amoxicillin/clavulanate

30 mg/kg po q 8 h (for children < 12 yr) or 500 mg po tid or 875 mg po bid (for adults) for 10 days. For inpatients, ampicillin/sulbactam

50 mg/kg IV q 6 h (for children) or 1.5 to 3 g (for adults) IV q 6 h (maximum 8 g ampicillin

/day) for 7 days is an option. Orbital cellulitis: Patients with orbital cellulitis should be hospitalized and treated with meningitis-dose antibiotics. A 2nd- or 3rd-generation cephalosporin, such as cefotaxime

50 mg/kg IV q 6 h (for children < 12 yr) or 1 to 2 g IV q 6 h (for adults) for 14 days, is an option when sinusitis is present; imipenem, ceftriaxone




are other options. If cellulitis is related to trauma or foreign body, treatment should cover gram-positive (vancomycin











100 mg IV once/day) pathogens and be taken for 7 to 10 days or until clinical improvement. Surgery to decompress the orbit, drain an abscess, open infected

sinuses, or a combination is indicated in any of the following circumstances:
   

Vision is compromised. Suppuration or foreign body is suspected. Imaging shows orbital or large subperiosteal abscess. The infection does not resolve with antibiotics.

Last full review/revision September 2008 by James Garrity, MD Content last modified September 2008