Blue Team Teaching Module: Periorbital/Orbital Infections

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Lewis Baldwin
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1 Blue Team Teaching Module: Periorbital/Orbital Infections Format: 1. Case 2. Topic Summary 3. Questions 4. References Case: A 3-year-old boy presents with 2 days of increasing redness, swelling, and pain around his left eye. He has a fever to On further history, he has seasonal allergies and has had 10 days of clear rhinorrhea and cough. On physical exam, you note that the left eye is swollen shut with marked swelling, erythema and tenderness of the lid. He requires restraint to manually open his eye, and it is difficult to assess range of motion of the eye because he is crying. How would you manage this child?

On further history, he has seasonal allergies and has had 10 days of clear rhinorrhea and cough.

2 Topic Summary: Definitions: Periorbital and orbital cellulitis are bacterial infections that affect the region around the eye. They may be difficult to distinguish from one another clinically as they both present with a red, painful, swollen eye. However the pathophysiology and treatment are different, therefore accurate diagnosis is essential. Overview: Periorbital cellulitis Orbital cellulitis Age Usually < 5 years Any age Risk factors Contiguous spread of infection, usually through break in skin Sinusitis >>orbital trauma, hematogenous spread Pathogens Staph aureus (including Staph aureus, strep, anaerobes, H. flu MRSA), strep Clinical exam Normal vision, ROM of eye, and no proptosis Proptosis, blurred vision, or ophthalmoplegia Diagnosis Usually by clinical exam Usually by CT scan of orbits Consultations None Ophthalmology (consider also ENT, ID) Management Usually Clindamycin or Bactrim to cover staph and strep Cephalosporin + Clinda or Unasyn + Bactrim (covers gram positives as well as anaerobes) Vancomycin for severe cases Surgical drainage if abscess is present Duration of 7-10 days 2-3 weeks antibiotics Complications Usually none Vision loss, intracranial spread of disease, orbital or subperiosteal abscess, cavernous sinus thrombosis

However the pathophysiology and treatment are different, therefore accurate diagnosis is essential.

3 Anatomy: The orbital septum is a thin membrane that separates the superficial eyelid from the deeper eye structures. Periorbital cellulitis, also known as preseptal cellulitis, is a bacterial infection of the eyelid and surrounding soft tissues that does not extend into the deeper orbital structures. In contrast, orbital cellulitis, also known as postseptal cellulitis, is an infection involving the fat and muscles posterior to the orbital septum. Clinical characteristics and pathophysiology: Periorbital cellulitis occurs most commonly in children less than 5 years of age. It is generally unilateral and most commonly originates from contiguous spread of infection, such as from an insect bite, scratch, eczema, or dacrocystitis. In contrast, orbital cellulitis can occur at any age and is most commonly a complication of sinus. Orbital cellulitis can also occur after trauma to the orbit or via hematogenous spread. Microbiology: The most common pathogens in periorbital cellulitis are staph aureus, including MRSA, and strep. In contrast, orbital cellulitis is often polymicrobial with similar pathogens to those seen in sinusitis. These include staph, strep, anaerobes and non-typeable Hemophilus influenza. Less common pathogens include Hemophilus influenza type B and Strep pneumo (since the advent of these vaccines), Neisseria and Moraxella. Physical exam: Distinguishing orbital from periorbital cellulitis requires an experienced examiner. Both present with swelling, redness, warmth, and tenderness of the eyelid, usually unilaterally and often with accompanying fever. A patient with periorbital cellulitis has a normal examination of the globe, including normal vision, full range of motion of the eye, and no proptosis. In this situation, periorbital cellulitis is a clinical diagnosis. Orbital cellulitis should be suspected in any patient who has proptosis, blurred vision, or ophthalmoplegia. If the vision or range of motion of the eyes cannot be properly assessed on exam, imaging and ophthalmology consultation should be strongly considered. Differential diagnosis: The differential diagnosis includes allergic reactions which are often bilateral and respond to antihistamines, and periorbital edema due to hypoalbuminemia, which is usually bilateral, not red or painful, and accompanied by edema of other parts of the body. Orbital pseudotumor is an idiopathic inflammation of the orbit which presents with proptosis, eye pain, visual changes, swelling, conjunctival injection, and ophthalmoplegia. A number of tumors including retinoblastoma, rhabdomyosarcoma, and neuroblastoma, may also present with proptosis. Indications for imaging: CT scan should be performed on any patient whose vision or range of motion of the globe cannot be properly assessed. In addition, CT should be performed when there are visual changes, proptosis, ophthalmoplegia, central nervous system findings, or lack of improvement after hours of appropriate treatment. CT scan of the orbits may reveal

In contrast, orbital cellulitis, also known as postseptal cellulitis, is an infection involving the fat and muscles posterior to the orbital septum.

4 infection extending from the sinuses into the orbital space, edema of the extraocular muscles, or an orbital or subperiosteal abscess. Management: Periorbital cellulitis may be managed with antibiotics that cover suspected pathogens based on local prevalence. Either oral or parenteral antibiotics are reasonable in a patient with periorbital cellulitis, depending on the severity of presentation. Typical duration of antibiotics is 7-10 days. Orbital cellulitis is managed as an inpatient initially with parenteral antibiotics. Ophthalmology should be consulted for all cases of orbital cellulitis with strong consideration of otolaryngology consultation as well. If infection is drained from an orbital abscess, subperiosteal abscess or sinus disease, cultures should be obtained and may help guide therapy. Empiric antibiotics should cover staph, strep, and other organisms associated with sinusitis. Reasonable regimens include a second- or thirdgeneration cephalosporin (to cover strep) plus clindamycin (to cover MRSA and anaerobes), or ampicillin-sulbactam (to cover strep and anaerobes) plus bactrim (to cover MRSA). Vancomycin should be used empirically for severe infections. Oral therapy can be considered once significant clinical improvement has been achieved for a total duration of 2-3 weeks of therapy. Complications: Complications of orbital cellulitis include orbital or subperiosteal abscess, cavernous sinus thrombosis, vision loss, and intracranial infection.

Either oral or parenteral antibiotics are reasonable in a patient with periorbital cellulitis, depending on the severity of presentation. Typical duration of antibiotics is 7-10 days.

5 Questions: 1. True or False: Periorbital cellulitis and preseptal cellulitis are synonyms. 2. True or False: Sinusitis that spreads contiguously through the bone is the most common cause of orbital cellulitis. 3. True or False: Outpatient management of periorbital cellulitis is appropriate in a well-appearing child with mild clinical exam findings, ability to tolerate oral medications, and close follow-up. 4. Radiological imaging is indicated in which of the following clinical scenarios? a. Fever with eye redness and blurry vision b. Proptosis c. Limited extraocular movements d. Inability to perform a complete orbital examination due to pain or swelling e. All of the above 5. The best empiric antibiotic for treatment of periorbital cellulitis is: a. Cephalexin b. Amoxicillin c. Clindamycin d. Metronidazole 6. Which of the following are potential routes for the development of orbital cellulitis? a. contiguous spread from ethmoid sinusitis b. hematogenous spread c. trauma to the globe d. extension from a periorbital infection e. all of the above 7. True or false: Most cases of orbital cellulitis require surgical drainage. 8. The most common pathogens implicated in orbital cellulitis are: a. Neisseria and Staph aureus b. Haemophilus influenza type B and Strep pneumo c. Group A strep and Moraxella catarrhalis d. Staph aureus and strep species 9. Complications of orbital cellulitis include all of the following EXCEPT:

True or False: Outpatient management of periorbital cellulitis is appropriate in a well-appearing child with mild clinical exam findings, ability to tolerate oral medications, and close follow-up. 4.

6 a. dental abscess b. meningitis c. intracranial abscess d. cavernous venous sinus thrombosis e. vision loss 10. The differential diagnosis of periorbital cellulitis includes all of the following EXCEPT: a. orbital cellulitis b. blepharitis c. orbital pseudotumor d. nephrotic syndrome e. allergic reaction

The differential diagnosis of periorbital cellulitis includes all of the

7 Answers: 1. True 2. True 3. True 4. e 5. c. Empiric antibiotics should include the most common pathogens, which include group A strep and staph aureus, including MRSA. 6. e 7. False. Most cases of orbital cellulitis can be successfully managed with antibiotics alone. 8. d 9. a 10. b. Blepharitis is inflammation of the eyelids at the area where the eyelashes originate. It usually results from blockage of the sebaceous glands. It does not usually produce significant swelling or erythema of the eyelids. Orbital cellulitis, orbital pseudotumor, and allergic reaction can cause swelling and redness of the eyelid. In addition nephrotic syndrome can cause swelling of the eyelid, usually without erythema. References: Hauser A, Fogarasi S. Periorbital and Orbital Cellulitis. Peds in Rev. 2010:31(6) Hunter D, Trucksis M. Preseptal (periorbital) and orbital cellulitis. UpToDate.com. Aug 11, Olitsky S, Hug D, Smith L. Orbital Infections. In Kliegman: Nelson Textbook of Pediatrics, 18 th Ed. Ch 633.

It usually results from blockage of the sebaceous glands. It does not usually produce significant swelling or erythema of the eyelids.

PRESEPTAL AND ORBITAL CELLULITIS IN CHILDREN- CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline

PRESEPTAL AND ORBITAL CELLULITIS IN CHILDREN- CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline 1.1. This guideline applies to medical and nursing staff caring for a child with Preseptal and Orbital