1. Orbital Cellulitis
Tal Marom, M.D.
September

2. Orbit anatomy
Frontal
Nasal
Ethmoid
Sphenoid
Lacrimal
Zygoma
Maxillary

3. 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

4. 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

5. 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

6. 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

7. Orbital septum

8. 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)

9. 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

10. 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

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

12. A male with orbital cellulitis with proptosis, ophthalmoplegia, and edema and erythema of the eyelids

14. Non-surgical treatment
IV ABx
Antifungals (if indicated)
Nasal decongestants (open sinus ostia)
Duretics – DIAMOX (carbonic anhydrase inhibitor), mannitol (reduce IOP)

15. Surgical Treatment
Surgical drainage if the response to appropriate antibiotic therapy is poor within 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 hours after appropriate antibiotics have been administered.
If brain abscesses develop and do not respond to antibiotic therapy, craniotomy is indicated.

16. How? Superior orbit decompression Medial orbit decompression
Inferior orbit decompression
Lateral orbit decompression
Intranasal approach

17. 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

19. 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

20. 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

21. Lateral Orbit Decompression
Lateral canthotomy
Removal of lateral orbital bone posterior to the rim
Orbital fat protrudes the newly created space

22. 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

24. Intranasal approach
Decompression of medial anf medioinferior floors of orbit
Endoscopic sinus surgery technique
Anterior Ethmoidectomy
Maxillary antrostomy