| Orbital Cellulitis  SIGNS AND SYMPTOMS
The patient with orbital cellulitis may be of any age or sex. There will be
noticeable lid edema and redness, distention, proptosis, and significant pain upon
palpation. Additionally, there will be diplopia from extraocular motility limitations.
There typically will be a precipitating factor such as penetrating lid trauma,
mucormycosis, orbital medial wall blow-out fracture, severe lid infectious disease, bite
wounds, meningitis, sinusitis and sinus infection, septicemia, ketoacidosis, or dental
abscess. Vision loss and an afferent pupil defect may often be present. The patient will
also be systemically ill and have a fever.
PATHOPHYSIOLOGY
Orbital cellulitis results from microbial infection with subsequent
inflammation of the post-septal aspect of the eyelids. The most common routes of infection
are from adjacent sinuses or teeth, and direct inoculation through penetrating lid injury.
Common organisms include Staphylococcus aureus, Streptococcus pyogenes, Streptococcus
pneumoniae, and Haemophilus influenzae in children. There is significant potential
morbidity and even mortality as a post-septal lid infection can spread through a valveless
venous system leading to cavernous sinus thrombosis, meningitis, intracranial infection,
and septicemia.
Inflammatory proptosis develops due to intraorbital abscesses of
mucopurulent material. Ophthalmoplegia develops as a result of toxic myopathy and soft
tissue edema. Vision loss will occur due to intraorbital increase in pressure from the
mucopurulent abscess, compressing the optic nerve.
MANAGEMENT
Differentiate orbital cellulitis from pre-septal cellulitis so as to
recognize a medical emergency. There are many superficial similarities between the two
diseases, namely lid edema and redness, and pronounced pain upon palpation. However,
orbital cellulitis manifests proptosis and extraocular muscle restriction, whereas
pre-septal cellulitis does not. Also, patients with orbital cellulitis have fever and
typically manifest decreased vision; these features are not present in pre-septal
cellulitis.
Often, the degree of proptosis in orbital cellulitis cannot be readily
appreciated due to the extreme lid edema. For this reason, CT scans are necessary, not
only to identify orbital abscesses, but also to ascertain precipitating sinus involvement.
There is no place for topical or oral antibiotic therapy in the
management of orbital cellulitis. Optimal management involves immediate consultation with
and referral to a primary care physician, pediatrician, or infectious disease specialist.
This is especially important with children as the potential for mortality is great. The
patient needs immediate hospitalization with in-patient parenteral antibiosis.
CLINICAL PEARLS
- When encountering a suspected orbital cellulitis, look for precipitating
factors such as sinus infection, bite wounds, dental abscess, and penetrating injury.
- Orbital cellulitis is a medical emergency and requires in-patient care.
- Patients with orbital cellulitis are systemically ill. The presence of
fever is highly diagnostic of post-septal orbital cellulitis. Patients who are
(tentatively) diagnosed with pre-septal cellulitis should be educated about the
seriousness of the development of fever.
- Post-septal orbital cellulitis will have motility restriction whereas
pre-septal cellulitis will not.
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