1. PeriOrbital and orbital Infections

2. Orbital Anatomy

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

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

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

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

7. 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

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

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

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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. dacryocystitis Management Antibiotics – systemic Warm compresses
Drainage

20. 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

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

22. 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

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

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

25. Preseptal Cellulitis
Other Causes of Eyelid Swelling
Insect bites

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

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

28. 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

29. 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

30. 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

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

32. 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

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

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

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

36. 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

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

38. 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

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

40. 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

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

42. 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)