Orbital Cellulitis

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Orbital Cellulitis
Tal Marom, M.D. September 2004
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Orbit anatomy
Frontal
Nasal
Ethmoid
Sphenoid
Lacrimal
Zygoma
Maxillary
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Orbital Cellulitis

• Orbital cellulitis is a dangerous infection with
  potentially serious complications
• It is usually caused by a bacterial infection
  from the sinuses (mainly ethmoid, accounting for
  more than 90 of all cases)
• Other causes a stye on the eyelid, recent trauma
  to the eyelid including bug bites, or a foreign
  object

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Children

• In children, orbital cellulitis is usually from a
  sinus infection and due to the organism
  Hemophilus influenzae (decrease in incidence
  after vaccination program implentation).
• Other organisms are Staphlococcus aureus,
  Streptococcus pneumoniae, and Beta hemolytic
  streptococci

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Pathophysiology

• extension of infection from the periorbital
  structures, most commonly from the paranasal
  sinuses, but also from the face, globe, and
  lacrimal sac
• direct inoculation of the orbit from trauma or
  surgery (orbital decompression,
  dacryocystorhinostomy, eyelid surgery, strabismus
  surgery, retinal surgery, and intraocular
  surgery, have been reported as the precipitating
  cause of orbital cellulitis)
• hematogenous spread from bacteremia

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Orbital septum

• The orbit is separated from the soft tissue of
  the eyelid by the orbital septum. This is a
  fascial plane that is continuous with the
  periosteum of the facial bones.
• The orbital septum inserts into the tarsal plate
  of the upper and lower eyelids.
• The orbital septum usually proves to be an
  effective barrier that prevents the spread of
  infection from the eyelids posteriorly to the
  orbit.
• While preseptal cellulitis can occasionally
  spread to the orbital contents, it is generally a
  clinical entity that is distinct from orbital
  cellulitis

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Orbital septum
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Orbital vs. Preseptal Cellulitis

• Orbital cellulitis is infection of the soft
  tissues of the orbit posterior to the orbital
  septum, differentiating it from preseptal
  cellulitis, which is infection of the soft tissue
  of the eyelids and periocular region anterior to
  the orbital septum
• DD orbital pseudotumor (inflammatory condition,
  responds to steroids)

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Chandler Classification

• Stage I Inflammatory edema-Preseptal
• Stage II Orbital cellulitis - Postseptal
• Stage III Subperiostal abscess
• Stage IV Orbital abscess
• Stage V Complication due to posterior
  extension

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Symptoms

• Fever, generally 102 degrees F or greater.
• Painful swelling of upper and lower lids (upper
  is usually greater).
• Eyelid appears shiny and is red or purple in
  color.
• Infant or child is acutely ill or toxic.
• Eye pain especially with movement.
• Decreased vision (because the lid is swollen over
  the eye).
• Eye bulging (forward displacement of the eye).
• Swelling of the eyelids
• General malaise.
• Restricted or painful eye movements

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Complications

• Subperiostal/Orbital abscess (Chandler III-IV)
• Cavernous sinus thrombosis
• Hearing loss
• Septicemia or blood infection
• Meningitis
• Optic nerve damage and blindeness

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A male with orbital cellulitis with proptosis,
ophthalmoplegia, and edema and erythema of the
eyelids
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Non-surgical treatment

• IV ABx
• Antifungals (if indicated)
• Nasal decongestants (open sinus ostia)
• Duretics DIAMOX (carbonic anhydrase inhibitor),
  mannitol (reduce IOP)

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Surgical Treatment

• Surgical drainage if the response to appropriate
  antibiotic therapy is poor within 48-72 hours or
  if the CT scan shows the sinuses to be completely
  opacified.
• Consider orbital surgery, with or without
  sinusotomy, in every case of subperiosteal or
  intraorbital abscess formation.
• Surgical drainage of an orbital abscess is
  indicated if any of the following occurs
  decrease in vision, An afferent pupillary defect.
  proptosis progresses despite appropriate
  antibiotic therapy
• The size of the abscess does not reduce on CT
  scan within 48-72 hours after appropriate
  antibiotics have been administered.
• If brain abscesses develop and do not respond to
  antibiotic therapy, craniotomy is indicated.

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How?

• Superior orbit decompression
• Medial orbit decompression
• Inferior orbit decompression
• Lateral orbit decompression
• Intranasal approach

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Superior Orbit Decompression

• Frontal cranioitomy unroofing of superior wall
  of orbit
• Titanium sheild placed to support the frontal
  lobe of the brain
• High morbidity, consider only for severe cases

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Medial Orbit Decompression

• External ethmoidectomy incision or coronal
  forehead approach
• External ethmoidectomy- complete ethmoid sinus
  resection, then orbital fat herniates into sinus
  defect
• Coronal incision- ethmoidectomy via a superior
  approach, more risk for lacrimal sac and trochlea
  injury

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Inferior Orbit Decompression

• Orbital floor blow-out fracture , but spares
  infraorbital nerve
• Subcilliary eyelid incision or Caldwell-Luc
  incision
• Combined approach?
• Intraorbital fat herniates maxillary sinus

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Lateral Orbit Decompression

• Lateral canthotomy
• Removal of lateral orbital bone posterior to the
  rim
• Orbital fat protrudes the newly created space

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An incision extending from the lateral canthus to
the area just below the inferior punctum is
created 4 mm to 5 mm below the lower border of
the tarsal plate to avoid injury to the septum
and the canaliculus
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Intranasal approach

• Decompression of medial anf medioinferior floors
  of orbit
• Endoscopic sinus surgery technique
• Anterior Ethmoidectomy
• Maxillary antrostomy