orbital and periorbital infectioun

PeriOrbital and orbital Infections

Orbital Anatomy

Orbital Septum

Fibrous Membrane separating the orbital and preseptal compartment

Upper Eyelid

Extends from the periosteum of the orbital rim to the levator aponeurosis

Lower Eyelid

Extends from the periosteum of the orbital rim to the inferior border of the tarsal plate

Routes of Infection Extension to lids and orbit

Indirect spread
• venous drainage system shared by cranial and midface structures
• multiple anastomoses and valveless System

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

Preseptal cellulitis

• An infection or inflammatory process of the eyelids and periorbital structures
• Occurs anterior to and contained by the orbital septum




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

Cellulitis - Common Etiologies

• Spread from adjacent structures – Skin and Sinuses
• Direct inoculation following Trauma
• Bacterial spread Upper Respiratory or Middle Ear

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


Chalazion
Most common inflammatory Lesion of eyelid
Blocked meibomian gland
Inflammatory nodule/cyst
Lipogranulomatous
Not infectious
Typically not painful

Chalazion

Managed by warm compresses and massage
Excision/ Steroid Injection

Chalazion

Prevention
Routine use of warm compresses
Lid margin Cleansing
Low dose oral doxycycline

Erysipelas

Superficial cellulitis
Usually group A Strep
Intensely erythematous with sharply demarcated border

hordeolum

Bacterial Infection
mebomian gland or ciliary glands (zeiss or moll)
Internal or external
Typically painful
May lead to preseptal cellulits

hordeolum

Management
Staphylococcal - most common etiology
Systemic Antibiotics
Lance/Drain

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

dacryocystitis

Management
Antibiotics – systemic
Warm compresses
Drainage

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

Herpes Zoster Dermatoblepharitits

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

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

Preseptal Cellulitis

Other Causes of Eyelid Swelling
contact dermatitis
Insect bites
Thyroid Eye Disease
Dacryoadenitis


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

Preseptal Cellulitis

Other Causes of Eyelid Swelling
Insect bites
•

Preseptal Cellulitis

Other Causes of Eyelid Swelling
Thyroid Eye Disease
Periorbital edema

Preseptal Cellulitis

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

•

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


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

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

Orbital Cellulitis

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

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

Orbital Cellulitis

Noninfectious causes of orbital inflammatory disease

Inflammatory and Autoimmune

thyroid ophthalmopathy
orbital pseudotumor
lymphoma
dermatomyositis-polymyositis
Wegener granulomatosis
Sjogren syndrome

Orbital Cellulitis

Noninfectious causes of orbital inflammatory disease

Vascular
orbital venous malformation
cavernous sinus thrombosis
Arteriovenous fistula
superior vena cava syndrome

Orbital Cellulitis

Noninfectious causes of orbital inflammatory disease

Neoplasms of orbit and lacrimal gland
pediatric: rhabdomyosarcoma, leukemia, metastatic neuroblastoma, retinoblastoma
adult: lymphoma

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


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

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

Orbital Cellulitis

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

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

Orbital Cellulitis

Surgical Management
If orbital abscess present
Early drainage of involved sinus
if orbital signs progressing

Feature

Preseptal
Orbital
Proptosis
Absent
Present
Motility
Normal - pain
Decreased + pain and double vision
Vision
Normal
Reduced – check vision and color vision
Pupillary Reaction
Normal
+/- APD – check swinging flashlight test
Chemosis
Rare
Common
Corneal Sensation
Normal
May be reduced
Systemic Signs
Absent/Mild
Commonly severe (Fever/Leukocytosis)
Differentiating features of cellulitis