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- Acute, severe, vision-threatening infection of orbital contents posterior to orbital septum. Preseptal (previously referred to as periorbital) cellulitis is anterior to the septum. Distinguishing location determines the appropriate workup and treatment.
- Synonym(s): postseptal cellulitis
- Differentiating orbital from preseptal cellulitis is the critical diagnostic step. Preseptal cellulitis can be identified by exam or, if needed, by CT scan.
- Both preseptal and orbital cellulitis present with a red, swollen painful eye or eyelid.
- Diplopia, proptosis, vision loss, and fever suggest orbital involvement.
- Contrast CT is the imaging method of choice and must be done for suspicion of orbital cellulitis.
- Treat with immediate IV antibiotics, hospital admission, and ophthalmology referral.
- Monitor frequently for vision loss, cavernous sinus thrombosis, abscess, and meningitis.
- No difference in frequency between genders in adults
- More common in children; mean age of surgical cases: 10.1 years; medical pediatric cases: 6.1 years
- Much less common than preseptal cellulitis
Etiology and Pathophysiology
- Sinusitis is classically associated with orbital cellulitis. Local skin conditions are typically associated with preseptal cellulitis.
- The ethmoid sinus is separated from the orbit by the lamina papyracea (“layer of paper”), a thin bony separation, and is often the source of contiguous spread of infection to the orbit.
- The orbital septum is a connective tissue barrier that extends from the skull into the lid and separates the preseptal from the orbital space.
- Cellulitis in the closed bony orbit causes proptosis, globe displacement, orbital apex syndrome (mass effect on the cranial nerves), optic nerve compression, and vision loss.
- Cultures of surgical specimens in adults often grow multiple organisms. In over 1/3 of cases, no pathogen is recovered (3)[B].
- Most common organisms (1,2)[C]:
- Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus anginosus
- Less common organisms:
- Moraxella catarrhalis, H. influenzae, group A β-hemolytic Streptococcus, Pseudomonas aeruginosa, anaerobes, phycomycosis (mucormycosis), aspergillosis, Mycobacterium tuberculosis, Mycobacterium avium complex, trichinosis, Echinococcus
- There are increasing cases of methicillin-resistant S. aureus (MRSA).
No known genetic predisposition
- Sinusitis present in 80–90% of cases (1)[C]
- Orbital trauma, retained orbital FB, ophthalmic surgery
- Dental, periorbital, skin, or intracranial infection; acute dacryocystitis (inflammation of the lacrimal sac) and acute dacryoadenitis (inflammation of the lacrimal gland)
- Atopy and HSV can lead to recurrent episodes (2).
- Immunosuppressed patients are at increased risk of adverse outcomes.
- Routine Hib vaccination
- Appropriate treatment of bacterial sinusitis
- Proper wound care and perioperative monitoring of orbital surgery and trauma
- Avoid trauma to the sinus and orbital regions.
- High index of suspicion in febrile patients presenting with periocular pain, swelling, and erythema
Commonly Associated Conditions
- Trauma and intraorbital FB
- Preseptal cellulitis
- Adverse outcomes of orbital apex syndrome, vision loss, ophthalmoplegia, abscess, meningitis, or cavernous sinus thrombosis