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ORBITAL CELLULITIS
The major infections of the ocular adnexal and
orbital tissues.
An infection of the soft tissues of the orbit
posterior to the orbital septum, differentiatin
g it from preseptal cellulitis, which is an infec
tion of the soft tissue of the eyelids and perio
cular region anterior to the orbital septum

ETIOLOGY
Extension of an infection from the periorbital
structures - Most commonly from the
paranasal sinuses, but also from the face, t
he globe, and the lacrimal sac
Direct inoculation of the orbit from trauma or
surgery
Hematogenous spread from bacteremia

ETIOLOGY
Extension of infection

most commonly in all age groups by ethmoid sinusitis (more than

90% of all cases)
aerobic, non-sporeforming bacteria
edema of the sinus mucosa => narrowing of the ostia =>
reduction or cessation of normal sinus drainage => microflora pr
oliferate and invade the edematous mucosa, resulting in suppura
tion
The organisms gain access to the orbit through thin bones of the
orbital walls, venous channels, foramina, and dehiscences.

ETIOLOGY

Extension of infection
infection of the maxillary sinus secondary to dental
infections anaerobes (commonly Bacteroides
species).
dacryocystitis: S aureus, S. pneumoniae,
Streptococcus pyogenes, and H. influenzae
Infections spreading from the soft tissues of the
eyelids and face: staphylococci and S. pyogenes

ETIOLOGY

Traumatic causes
accidental (eg, orbital fracture) or surgical
trauma
within 48-72 hours after injury
in the case of a retained orbital foreign body,
it may be delayed for several months.

ETIOLOGY
Bacterial causes

most common: Streptococcus species, Staphylococcus aureus, and

Haemophilus influenzae type B
less common: Pseudomonas, Klebsiella, Eikenella, and Enterococcus
Polymicrobial infections with aerobic and anaerobic bacteria are
more common in patients aged 16 years or older.

ETIOLOGY

Fungal causes
most common: Mucor and Aspergillus
species.
Fungal infections carries a high mortality
rate in patients who are immunosuppresse
d.

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CLINICAL MANIFESTATIONS
- Ocular pain
- Eyelid swelling with
erythema
- Pain on eye movement
- Proptosis
- Opthalmoplegia with
diplopia
- Conjunctival chemosis

Fever
Headache
Rhinorrhea
Vision impairment

A male patient with orbital

cellulitis with proptosis,
ophthalmoplegia, and edema
and erythema of the eyelids.
The patient also exhibited pain
on eye movement, chemosis,
fever, headache, and malaise

Orbital cellulitis due to

sinisitis

DIAGNOSIS(PHYSICAL EXAMINATION)
Proptosis (advance rapidly progression)
Opthalmoplegia (advance rapidly progression)
Conjuctival chemosis
Decreased vision (may be normal in early)
Elevated intraocular pressure
Pain on eye movement
Orbital pain and tenderness (early sign)

DIAGNOSIS(PHYSICAL EXAMINATION)

Dark red discoloration of the eyelids

Hyperemia of conjunctiva
Resistance to retropulsion of the globe
Purulent nasal discharge

DIAGNOSIS(LAB)
Complete blood count
- WBC greater than 15000 cell/cu.mm.
Blood cultures
- prior to the administration of any ATB
Purulent material assessment
- collect purulent material from the nose
- gram stain, culture

DIAGNOSIS(LAB)
CT scanning with contrast infusion

- axial views include low, narrow cuts of the frontal lobes

R/O peridural and brain abscesses formation
- coronal views helpful in determining the presence and
extent of any subperiorbital abscesses
MRI

-helpful in defining orbital abscesses and possibility of

cavernous sinus disease

DIAGNOSIS(LAB)
Lumber puncture
- advisable if cerebral or meningeal sign
develop

Needle aspiration of the orbit

is contraindicated

DIFFERENTIAL DIAGNOSES
Exophthalmos
Mucormycosis
Retinoblastoma
Sarcoidosis
Spider Bites
Thyroid Ophthalmopathy

COMPLICATION

SUBPERIOSTEAL ABSCESS
Subperiosteal abscess is a fairly common
complication of orbital cellulitis, occurring in 15
to 59 percent of cases in various retrospective
series. It is difficult to distinguish subperiosteal
abscess from simple orbital cellulitis on clinical
grounds, although marked displacement of the
globe is suggestive of abscess. Orbital imaging
or surgery is necessary to make the diagnosis.

ORBITAL ABSCESS
Like subperiosteal abscess, orbital abscess is
difficult to distinguish from uncomplicated orbi
tal cellulitis. It has been reported in up to 24 p
ercent of cases of orbital cellulitis. Patients wi
th orbital abscess typically have more severe s
igns (proptosis, ophthalmoplegia) and sympto
ms (pain with eye movements) than those with
uncomplicated orbital cellulitis.

EXTRAORBITAL EXTENSION
Infection may rarely extend to the orbital apex, causing visual
loss, or intracranially, causing epidural or subdural empyema,
brain abscess, meningitis, cavernous sinus thrombosis, or dur
al sinus thrombosis. The visual loss associated with orbital cell
ulitis is thought to result from any of the following processes:
Optic neuritis as a result of inflammation from nearby infection
Ischemia resulting from thrombophlebitis along the orbital
veins
Pressure resulting in central retinal artery occlusion

TREATMENT
- Pharmacologic
The usual choices are a parenterally
administered broad-spectrum regimen aimed
at
S. aureus (including methicillin-resistant S.
aureus [MRSA])
S. pneumoniae and other streptococci
gram-negative bacilli

TREATMENT
Appropriate antibiotic regimens for empiric treatment in
patients with normal renal function include a combination o
f
Vancomycin
Ceftriaxone
Cefotaxime
Ampicillin-sulbactam
Piperacillin-tazobactam

Patients should begin to show improvement within 24 to 48 hours of

initiating appropriate therapy; if this does not occur, repeat
imaging should be performed to search for an abscess or another i
ndication for surgery

TREATMENT
For patients with uncomplicated orbital cellulitis (ie,
without abscess or other complications) whose infection
responds well, it is reasonable to switch to oral therapy.
we suggest that antibiotics be continued until all signs of
orbital cellulitis have resolved, and for a total of at least
two to three weeks.
A longer period (at least four weeks), is recommended for
patients with severe ethmoid sinusitis and bony destruc
tion of the sinus.

TREATMENT
Indications for Surgical Drainage

A decrease in vision occurs.

An afferent pupillary defect develops.
Proptosis progresses despite appropriate antibiotic therapy.
The size of the abscess does not reduce on CT scan within
48-72 hours after appropriate antibiotics have been administer
ed; if brain abscesses develop and do not respond to antibiotic
therapy, craniotomy is indicated.
especially a large abscess (>10 mm in diameter)
The presence of a drainable fluid collection is evident on CT
scan in patients older than 16 years.