PeriOrbital and orbital Infections

Orbital Anatomy

Fibrous Membrane separating the orbital and preseptal compartment Orbital Septum Fibrous Membrane separating the orbital and preseptal compartment

Upper Eyelid Extends from the periosteum of the orbital rim to the levator aponeurosis

Lower Eyelid Extends from the periosteum of the orbital rim to the inferior border of the tarsal plate

Routes of Infection Extension to lids and orbit Indirect spread venous drainage system shared by cranial and midface structures multiple anastomoses and valveless System

Routes of Infection Extension to lids and orbit Direct spread Ethmoid sinus through lamina papyracea - contained subpereosteal abscess or progressive orbital involvement frontal and maxillary sinus Orbital floor Odontogenic – maxillary sinus - orbit

Preseptal cellulitis An infection or inflammatory process of the eyelids and periorbital structures Occurs anterior to and contained by the orbital septum

Orbital cellulitis Occurs posterior to the orbital septum Involves the soft tissue within the bony orbit

Cellulitis - Common Etiologies Spread from adjacent structures – Skin and Sinuses Direct inoculation following Trauma Bacterial spread Upper Respiratory or Middle Ear

Preseptal – Associated factors Hordeola and Chalazia Impetigo/Erysipelas Blepharitis Conjunctivitis Canaliculitis Dacryocystitis Viral dermatitis – herpes simplex & herpes zoster Eyelid swelling both causes and results from impeded venous flow and lymphatic drainage – leading to self-propagating process These are things that can mimic or lead to preseptal and potentially orbital cellulitis

Chalazion Most common inflammatory Lesion of eyelid Blocked meibomian gland Inflammatory nodule/cyst Lipogranulomatous Not infectious Typically not painful Oil-producing sebaceous glands located in the tarsal plates of upper and lower lids – chronic libogranulomatous inflammation

Chalazion Managed by warm compresses and massage Excision/ Steroid Injection Oil-producing sebaceous glands located in the tarsal plates of upper and lower lids – chronic libogranulomatous inflammation

Chalazion Prevention Routine use of warm compresses Lid margin Cleansing Low dose oral doxycycline Oil-producing sebaceous glands located in the tarsal plates of upper and lower lids – chronic libogranulomatous inflammation

Erysipelas Superficial cellulitis Usually group A Strep Intensely erythematous with sharply demarcated border Oil-producing sebaceous glands located in the tarsal plates of upper and lower lids – chronic libogranulomatous inflammation

hordeolum Bacterial Infection mebomian gland or ciliary glands (zeiss or moll) Internal or external Typically painful May lead to preseptal cellulits Meibomian Glands – within tarsal plate Zeis Glands – associated with lash follicles Glands of Moll – apocrine glands associated with eyelash follicles

hordeolum Management Staphylococcal - most common etiology Systemic Antibiotics Lance/Drain Meibomian Glands – within tarsal plate Zeis Glands – associated with lash follicles Glands of Moll – apocrine glands associated with eyelash follicles

dacryocystitis Pain, redness and swelling below the medial Canthal tendon Typically associated with blockage of the nasolacrimal System Tear stasis and retention → secondary bacterial infection

dacryocystitis Management Antibiotics – systemic Warm compresses Drainage

dacryocystitis Management Oral antibiotics Gram Positive bacteria most common Consider Gram neg in diabetics, immunocompromised patients IV antibiotics when severe/associated with orbital cellulitis drainage of abscess

Herpes Zoster Dermatoblepharitits Recurrence or reactivation of Varicella Zoster virus Burning, Stabbing pain of forehead/scalp Vesicular Rash in V1 distribution

Herpes Zoster Dermatoblepharitits treat with antivirals Acyclovir if identified within 72 hours of skin lesion onset treat with antivirals Acyclovir if identified within 72 hours of skin lesion onset

Preseptal Cellulitis Other Causes of Eyelid Swelling contact dermatitis Insect bites Thyroid Eye Disease Dacryoadenitis

Preseptal Cellulitis Other Causes of Eyelid Swelling contact dermatitis Thickened, Erythematous, scaly skin

Preseptal Cellulitis Other Causes of Eyelid Swelling Insect bites

Preseptal Cellulitis Other Causes of Eyelid Swelling Thyroid Eye Disease Periorbital edema

Preseptal Cellulitis Other Causes of Eyelid Swelling Dacryoadenitis Inflammation of lacrimal gland Superotmeporal pain, swelling, erythema “S” shaped lid deformity

Preseptal management Typically outpatient =oral antibiotics All children < 1 year old should be hospitalized with IV antibiotics Culture when able – more likely after traumatic insult Most common bacteria involved for adults: Staph aurues and Strep pyogenes Most common for children: h influenza type b and strep pneumonia If abscess develops it should be incised and drained

Preseptal Management Teenagers and Adults Usually arises from superficial source (trauma, chalazion) Treated with oral antibiotics Commonly Penicillinase-resistant penicillin or Bactrim Image if: source of infection not determined not responding quickly to treatment orbital process suspected

Preseptal Management Children The most common cause is underlying sinusitis Work up with CT quickly if no source of direct inoculation easily identified Hospitalize and IV antibiotics

Orbital Cellulitis Ophthalmic Signs Proptosis Motility Disturbance Pronounced edema and erythema Impaired vision with afferent pupil defect Conjunctival chemosis and hyperemia Reduced corneal sensation

Orbital cellulitis Sources of infection are similar to preseptal Extension of sinus disease Penetrating trauma Infected adjacent structures Other uncommon sources Scleral buckles, Aqueous drainage devices, endophthalmitis

Orbital Cellulitis Noninfectious causes of orbital inflammatory disease Inflammatory and Autoimmune thyroid ophthalmopathy orbital pseudotumor lymphoma dermatomyositis-polymyositis Wegener granulomatosis Sjogren syndrome

Orbital Cellulitis Noninfectious causes of orbital inflammatory disease Vascular orbital venous malformation cavernous sinus thrombosis Arteriovenous fistula superior vena cava syndrome

Orbital Cellulitis Noninfectious causes of orbital inflammatory disease Neoplasms of orbit and lacrimal gland pediatric: rhabdomyosarcoma, leukemia, metastatic neuroblastoma, retinoblastoma adult: lymphoma

Orbital Cellulitis > 90% of all related to underlying sinus disease In children usually single organism from sinus (s aureus or strep pneumonia) Adolescents and adults have more complex bacteriology (often 2-5 organisms) trauma – Gram - rods Dental – mixed, aggressive aerobes and anaerobes Immunocompromised/Diabetics - fungi

Orbital cellulitis Laboratory studies CBC Nasal swab if purulent material Blood cultures Lumbar puncture if meningeal signs present

Orbital cellulitis Imaging Studies Orbital CT Thin, axial and coronal, without contrast Include orbits, paranasal sinuses, frontal lobes If neurologic involvement include the head when imaging

Orbital Cellulitis Significant morbidity if not appropriately treated orbital apex syndrome blindness cavernous sinus thrombosis cranial nerve palsies meningitis intracranial abscess

Orbital Cellulitis Medical Management Admit for IV antibiotics cephalosporin – Ampicillin or Pipercillin Vancomycin for MRSA Clindamycin for anaerobic coverage Nasal decongestants Transition to outpatient oral antibiotics treatment for 1-3 weeks

Surgical Management Orbital Cellulitis If orbital abscess present Early drainage of involved sinus if orbital signs progressing

Differentiating features of cellulitis Preseptal Orbital Proptosis Absent Present Motility Normal - pain Decreased + pain and double vision Vision Normal Reduced – check vision and color vision Pupillary Reaction +/- APD – check swinging flashlight test Chemosis Rare Common Corneal Sensation May be reduced Systemic Signs Absent/Mild Commonly severe (Fever/Leukocytosis)