Orbital cellulitis

Bacterial orbital cellulitis is a life-threatening infectious inflammation of the soft tissues behind the tarso-orbital fascia.

Occurs at any age, but more often in children. The most common pathogens are Strep. pneumoniae, Staph. aureus, Strep. pyogenes and H. influenzae.

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What causes orbital cellulitis?

1. Sinusitis, most often ethmoiditis, usually affects children and young adults.
2. Extension of preseptal cellulitis through the tarso-orbital fascia.
3. Spread of local infection in dacryocystitis. Infections of the midface, teeth. In the latter case, orbital cellulitis is preceded by inflammation of the maxillary sinus.
4. Hematogenous dissemination.
5. Posttraumatic develops within 72 hours after damage to the tarso-orbital fascia. The clinical picture may be atypical in the presence of a scratch or hematoma.
6. Post-surgical as a complication of surgery on the retina, lacrimal organs or orbit.

Symptoms of Orbital Cellulitis

Orbital cellulitis is characterized by severe weakness, fever, pain and visual impairment.

• Unilateral lesion, pain, local increase in temperature, redness of the periorbital tissues and swelling of the eyelid.
• Exophthalmos, which is usually hidden by swelling of the eyelid, often with an outward and downward displacement.
• Ophthalmoplegia with pain when attempting to move the eye.
• Impaired function of the optic nerve.

Complications of orbital cellulitis

1. From the organ of vision: exposure keratopathy, increased intraocular pressure, occlusion of the central retinal artery or vein, endophthalmitis and optic neuropathy.
2. Intracranial (meningitis, brain abscess and cavernous sinus thrombosis) are rare. The latter is extremely dangerous and should be suspected in case of bilateral symptoms, rapidly increasing exophthalmos and congestion in the veins of the face, conjunctiva and retina. Additional signs: rapid increase in clinical symptoms of prostration, severe headache, nausea and vomiting.
3. Subperiosteal abscess is most often localized on the inner wall of the orbit. It is a serious problem because it can progress quickly and spread into the cranial cavity.
4. Orbital abscess is rarely associated with orbital cellulitis and develops after trauma or surgery.

Prefascial cellulite

Prefascial cellulitis is an infectious lesion of the soft tissues anterior to the tarso-orbital fascia. It is not actually an orbital disease, but is considered here because it must be differentiated from orbital cellulitis, a rarer and potentially more serious pathology. Sometimes, rapidly progressing, it develops into orbital cellulitis.

Reasons

• a skin injury, such as a scratch or insect bite. The pathogens are usually Staph. aureus or Strep. pyogenes;
• spread of local infection (chalazion or dacryocystitis);
• hematogenous transmission of infection from a distant infectious focus located in the upper respiratory tract or middle ear.

Symptoms: one-sidedness, pain, redness of the periorbital tissues and swelling of the eyelid.

Unlike orbital cellulitis, there is no exophthalmos. Visual acuity, pupillary reactions and eye movements are not impaired.

Treatment: orally co-amoxiclav 250 mg every 6 hours. In severe cases, intramuscular administration of benzylpenicillin may be required in a total of 2.4-4.8 mg per injection and orally flucloxacin 250-500 mg every 6 hours.

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Treatment of orbital cellulitis

1. Hospitalization with urgent ophthalmologic and otolaryngologic examinations is necessary. An intracranial abscess may require neurosurgical drainage.
2. Antibacterial therapy consists of intramuscular administration of ceftazidime 1 g every 8 hours and oral metronidazole 500 mg every 4 hours to suppress anaerobic infection. In case of penicillin allergy, intravenous vancomycin is used. Antibacterial therapy should be continued until the body temperature has been normal for 4 days.
3. Optic nerve function should be monitored every 4 hours by assessing pupillary reactions, visual acuity, color and eustoma perception.
4. Research on indications:
   • White blood cell count.
   • Blood culture.
   • CT of the orbit, sinuses, brain. CT of the orbit helps differentiate severe preseptal cellulitis from orbital cellulitis.
   • Lumbar puncture in the presence of meningeal or cerebral symptoms.
5. Surgery should be considered when:
   • Ineffectiveness of antibiotics.
   • Decreased vision.
   • Orbital or sub-osteal abscess.
   • Atypical clinical picture and the need for biopsy.

It is usually necessary to drain the infected sinus as well as the orbit.