Orbital CellulitisOrbital Cellulitis

Tal Marom, M.D.

September 2004

Orbit anatomyOrbit anatomy

Frontal

Zygoma

Maxillary

NasalEthmoid

LacrimalSphenoid

Orbital CellulitisOrbital CellulitisOrbital cellulitis is a dangerous infection with

potentially serious complicationsIt 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

ChildrenChildren

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

PathophysiologyPathophysiology

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

Orbital septumOrbital 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

Orbital septumOrbital septum

Orbital vs. Preseptal CellulitisOrbital 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)

Chandler ClassificationChandler 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

SymptomsSymptoms

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

ComplicationsComplications

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

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

Non-surgical treatmentNon-surgical treatment

IV ABxAntifungals (if indicated)Nasal decongestants (open sinus ostia)Duretics – DIAMOX (carbonic anhydrase

inhibitor), mannitol (reduce IOP)

Surgical TreatmentSurgical Treatment1. Surgical drainage if the response to appropriate antibiotic

therapy is poor within 48-72 hours or if the CT scan shows the sinuses to be completely opacified.

2. Consider orbital surgery, with or without sinusotomy, in every case of subperiosteal or intraorbital abscess formation.

3. 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

4. The size of the abscess does not reduce on CT scan within 48-72 hours after appropriate antibiotics have been administered.

5. If brain abscesses develop and do not respond to antibiotic therapy, craniotomy is indicated.

HowHow ? ?

Superior orbit decompressionMedial orbit decompressionInferior orbit decompressionLateral orbit decompressionIntranasal approach

Superior Orbit DecompressionSuperior 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

Medial Orbit DecompressionMedial 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

Inferior Orbit DecompressionInferior Orbit DecompressionOrbital floor blow-out fracture , but spares

infraorbital nerveSubcilliary eyelid incision or Caldwell-Luc

incisionCombined approach? Intraorbital fat herniates maxillary sinus

Lateral Orbit DecompressionLateral Orbit DecompressionLateral canthotomyRemoval of lateral orbital bone posterior to the

rimOrbital fat protrudes the newly created space

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

Intranasal approachIntranasal approachDecompression of medial anf medioinferior

floors of orbitEndoscopic sinus surgery techniqueAnterior EthmoidectomyMaxillary antrostomy