ORBITAL CELLULITIS

Signs and Symptoms

Orbital cellulitis is a vision-threatening infection of the tissues of the orbit.1-5 The condition results from direct spread of infection from the ocular adnexa and adjacent orbital structures to the orbit.6-13 Signs and symptoms include exophthalmos (proptosis), ocular displacement with or without diplopia, conjunctival chemosis, eye lid edema with injection, palpable warmness, pain upon palpation, blurred vision, possible relative afferent pupillary defect, ophthalmoplegia, generalized malaise and fever.5-7

Rare in general ophthalmic practice, orbital cellulitis is more common in children than adults.14,15 It has been organized using the modified Chandler classification into two forms: the preseptal form (Stage I-Preseptal cellulitis, Stage II-orbital cellulitis, anterior to the orbital septum) and the retroseptal form (Stage III-Subperiosteal abscess, Stage IV-Orbital abscess, Stage V-Cavernous sinus thrombosis) posterior to the orbital septum.2,8 Etiologies include spread of dental infection, frontal subperiosteal abscess associated with and without underlying frontal bone osteomyelitis (Pott’s puffy tumor), dacryoadenitis, lacrimal gland abscess, sinusitis (rhinosinusitus), trauma, eyelid infection secondary to puncture wound, foreign body, meningitis and intraocular retinoblastoma.6-21 Documented systemic illnesses increasing the risk of an event include diabetes, septicemia, malignancy and immunosuppresion.7 In adults, there may be a slight predilection for male gender.22

Pathophysiology

The etiology of orbital cellulitis is secondary to one of two mechanisms: either direct invasion to the region or infection spread through the blood stream to the paranasal air sinuses, which communicate with orbital contents.19-27 Ultimately, the condition induces its life- and vision-threatening complications by way of infection proliferation within the enclosed compartment of the orbit and cranium.1-27 The infection has the capability to dissect under the periosteum of the orbital bones and lead to subperiosteal abscess or intraorbital abscess with formed progressive cellulitis.26-28

The associated activation of immunological cytokines and chemoattractants impact visual function through mechanical compression. Vision loss in orbital cellulitis occurs via compressive optic neuropathy, where the volume of orbital edema and infection expands applying pressure against the nerve arresting its normal function and limiting its perfusion. Chronic perfusion interruption induced by mass effect can cause tissue death and permanent dysfunction.

Organisms involved in orbital cellulitis include anaerobic, aerobic and microaerophilic bacteria, fungi and parasites.24-36 The common organisms include Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, group A-hemolytic streptococci, other streptococcal species, anaerobes such as Pseudomonas and methicillin-resistant Staphylococcus aureus (MRSA).1-4,8-22,33,37

Fungal infections of the orbit tend to occur primarily in immunocompromised individuals.35 One particularly aggressive subtype of mucormycosis caused by Apophysomyces elegans has been reported as occurring in immunocompetent individuals after contamination from traumatic inoculation.35,36

The medial orbital wall is thin and fenestrated, occupied by numerous small vessels and nerves along with natural communicative defects (Zuckerkandl dehiscences).24,26-28 The combination of thin bone, with foramina and naturally occurring defects, allows for communication of infectious material between the ethmoid air cells and the subperiorbital space.27,28 The periorbita (periosteal lining), in the region of the medial orbital wall is adherently loose. Infections taking root in this region may easily move laterally, superiorly and inferiorly within the subperiorbital space.24,26-28 Additionally, the intermuscular septa of the extraocular muscles along with adipose tissue extend from muscle insertions to their origins at the annulus of Zinn (posteriorly), making infection extension between the extraconal and intraconal orbital spaces possible.29-31

The fibroadipose tissue in the eyelid and eyebrow along with fibrous septa within the submuscular fibroadipose tissue become contiguous with more compact lamellae of the orbital septum posteriorly making spread of infection within the eyelid tissues possible. Since venous drainage from the middle third of the face, orbit and paranasal sinuses is mainly via the veins without valves that connect to the orbit, infections in the region may move anterograde or retrograde.22-31

Management

The retroseptal form of orbital cellulitis, sometimes referred to as “true” orbital cellulitis, is the most severe presentation of the disease.1 It has the ability to impact vision and survival. 1-4,8-22,33,37 Clinical examination and urgent CT or MRI scanning with contrast are necessary in the evaluation of the extent and severity, surgical planning and antibiotic selection.1-4,8-22,33,37-40

Orbital inflammation should be classified by the modified Chandler’s criteria as preseptal or postseptal. Most preseptal cases (Chandler I, II) respond to oral antibiotics.1-4,8-22,33,37,38 Most cases of postseptal cellulitis (Chandler III, IV, V) are managed with intravenous antibiotics, although surgical therapy is required for some abscesses when improvement is not seen within 48 hours of intravenous treatment.26,38

Children under nine years of age respond better to medical management than older patients, but recent studies confirm that even children over age nine with small or moderate-sized abscesses and normal vision should undergo medical antibiosis before surgical intervention.38 Medial subperiosteal abscesses that fail medical therapy are usually drained endoscopically, whereas lateral or intraconal abscesses require an open procedure.38

The oral antibiotics of first choice should be a broad spectrum agent with good central nervous system penetration such as clindamycin or third-generation cephalosporins.38 Intravenous agents include the third-generation cephalosporin such as cefotaxime, ceftriaxone or cefuroxime.38 Orbital cellulitis with any nasal origin or any spread to the ethmoidal region can impact breathing. Secondary nasal congestion can be treated with topical oxymetazoline or Afrin nasal spray QD.38

Ocular aspects of orbital cellulitis that require local intervention include lowering elevated intraocular pressure occurring from compressive and congestive forces and treating any concomitant anterior uveitis.39-42

Clinical Pearls

Orbital cellulitis is a leading cause of proptosis in children.

Insect bites, especially those obtained via spiders are known etiologies of orbital cellulitis.

Orbital cellulitis is a vision- and life-threatening condition. These patients should be referred to an infectious disease specialist for hospital admission.

Prompt medical attention is required to preserve function and reduce the risk of extreme complications such as cavernous sinus thrombosis, meningitis, brain abscess and blood sepsis.43

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43. Pandian DG, Babu RK. A Chaitra, et al. Nine years’ review on preseptal and orbital cellulitis and emergence of community-acquired methicillin-resistant Staphylococus aureus in a tertiary hospital in India. Indian J Ophthalmol. 2011; 59(6):431-5.