1. Periorbital vs Orbital Cellulitis
Morning Report 7/25/12
Melanie McIntosh

2. Anatomy
Orbital septum – thin membrane separates superficial eyelid from deeper structures; barrier to infection
Anterior – periorbital cellulitis; posterior – orbital cellulitis
Risk for infection spread: thin/incomplete septum, sinuses  through bone  orbit, valveless veins – hematogenous spread

3. Pathogenesis Rhinosinusitis (especially ethmoiditis)
Extension of external ocular infection
Stye, dacryocystitis/dacryoadenitis
Skin trauma (insect bites, acne, surgery)
Dental abscess
Hematogenous seeding

4. Epidemiology More common overall Age <5yrs M=F All ages 2:1 M>F
Periorbital Cellulitis
Orbital Cellulitis
More common overall
Age <5yrs
M=F
All ages
Average: 6.8 yrs
2:1 M>F
Associated with sinusitis and URIs
More common in winter
Periorbital 3x more common

5. Clinical Presentation
Unilateral erythema, edema, warmth, tenderness of eyelid
Fever, systemic illness can be seen
Orbital Cellulitis – increased intra-orbital pressure
Vision changes (i.e. diplopia)
Ophthalmoplegia
Proptosis
Chemosis
Limited EOM
Reduced visual acuity
Abnormal light reflexes

6. Differential Diagnosis
Edema
Allergic Reaction
Hypoproteinemia
Sickle Cell – orbital wall infarction, subperiosteal hematoma
Proptosis
Orbital Pseudotumor
Graves Disease - exophthalmos
Allergic – responds to benadryl; hypoprotein – bilateral
Pseudotumor – pain, proptosis, edema, injection, ptosis, limited EOM, vision changes; Need CT scan - corticosteroids

7. Diagnostic Work-up Periorbital Cellulitis – typically clinical dx
EOMI
Orbital Cellulitis
Elevated WBC, CRP, ESR (but DO NOT use alone to make the diagnosis!)
Wound Culture
CT Scan c contrast
Edema  unable to examine eye
CNS involvement
Loss of visual acuity, proptosis, ophthalmoplegia
Worsening/no improvement after 24-48hrs tx
Periorbital – doesn’t have some of the more concerning signs of orbital (increased intraorbital pressure)
Wbc, crp, esr – not diagnostic but suggestive
Wound culture – determine abx sensitivities; BCx low yield…so not required unless patient looks toxic/ill-appearing

8. Contrast CT – Orbital Cellulitis
Proptosis
Intraorbital free air
Diffuse fat infiltration

9. Indications for Inpatient Admission
Diplopia, loss of visual acuity, abnormal light reflexes, proptosis, ophthalmoplegia
CNS Involvement
Lethargy, vomiting, HA, seizures, focal deficits, altered mental status
Inability to fully examine eye

10. Pathogens 75% Staph & Strep H. influenza type b S. pneumo
S. epidermidis, S. aureus, S. pyogenes
MRSA
H. influenza type b
S. pneumo
Polymicrobial
Especially seeding from dental abscess
Hflu/Spneumo – immunizations UTD?

11. Treatment Staph and Strep coverage MRSA PO = IV 7-10 days
Periorbital Cellulitis
Orbital Cellulitis
Staph and Strep coverage
MRSA
PO = IV
7-10 days
Should see improvement in hrs
Coverage for Staph, Strep, and organisms causing rhinosinusitis
MRSA
10-14 days
Start with IV, but may switch to PO after seeing improvement
Surgery
Surgery – drain abscess, release pressure, get culture

12. Complications – Periorbital Cellulitis
Recurrent Periorbital Cellulitis (RPOC)
3 infections within 1 yr, spaced by at least one month
Not due to treatment failure
Underlying causes
Atopy
Nonbacterial organisms – HSV, Mycobacteria
Collagen Vascular Disorders
Structural abnormalities
Immunosuppression

13. Complications – Orbital Cellulitis
Cavernous Sinus Thrombosis
Acute or slowly progressive symptoms of orbital cellulitis
Proptosis, periorbital edema, and ophthalmoplegia
Late Signs: vision loss, meningismus
Intracranial Infections
Subdural empyema, Intracerebral abscess, Extradural abscess, Meningitis
Optic Nerve Damage – vision loss
Septic emboli
Compression  ischemia