49 y/o with swelling and redness around the eye
Patient will present as → a 49-year-old man presents to the emergency department with a 2-day history of right eye pain, swelling, and decreased vision. On examination, he has proptosis, ophthalmoplegia (paralysis of the extraocular muscles), and chemosis of the right eye. His temperature is 101°F (38.3°C), and blood cultures are pending. A CT scan of the orbits shows evidence of an abscess in the right orbit.
Orbital cellulitis is an infection of the orbital muscles and fat behind the eye (differentiate from periorbital cellulitis, which is only an infection of the skin)
- Patients will present with decreased extraocular movement (ophthalmoplegia), pain with movement of the eye, and proptosis (protrusion of the eye)
- May present with fever, decreased vision, and diplopia
- Often associated with untreated sinusitis. It occurs more often in children than adults - ages 7-12 y/o
- The most common pathogens are Staphylococcus aureus and streptococci (S. anginosus, S. pyogenes, S. pneumoniae). Nontypeable Haemophilus influenzae remains a cause when orbital cellulitis follows sinusitis, but H. influenzae type b (Hib) is now rare because of vaccination
- Decreased vision is a rare manifestation of orbital cellulitis
Involvement of muscles and fat behind the eye. Image: Jonathan Trobe, M.D., University of Michigan Kellogg Eye Center, CC BY 3.0, via Wikimedia Commons.
History, clinical exam, and focused assessment of extraocular muscles
- The imaging modality of choice for the diagnosis of orbital cellulitis is CT with contrast
- CBC and blood culture may be standard in some settings
CT showing odontogenic infection extending into the right maxillary sinus and orbit. Image: James Heilman, MD, CC BY-SA 3.0, via Wikimedia Commons.
If orbital cellulitis/abscess is seen on CT, it requires an ophthalmology evaluation
- Hospitalization and IV broad-spectrum antibiotics
- Vancomycin + ceftriaxone/cefotaxime is used in the empiric treatment of orbital cellulitis to cover methicillin-resistant Staphylococcus aureus (MRSA)
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Question 1 |
Which of the following clinical findings differentiates periorbital from orbital cellulitis?
erythema Hint: See D for explanation | |
fever Hint: See D for explanation | |
lid edema Hint: See D for explanation | |
worsening pain with eye movements | |
development of a rash on the face Hint: See D for explanation |
Question 1 Explanation:
Periorbital cellulits is characterized by warmth, redness, swelling, and tenderness over the affected eye, along with conjunctival injection, eyelid swelling, chemosis, and fever. Orbital cellulitis includes all the symptoms of periorbital (preseptal) cellulitis with the addition of ocular pain and limitation of eye movement. Other physical examination findings may include lid edema, proptosis, marked tenderness to the globe, decreased visual acuity, and pupillary paralysis.
Question 2 |
The most common organism isolated in periorbital cellulitis in vaccinated children in the absence of trauma is
H. influenzae type B Hint: Before widespread immunization, Haemophilus influenzae type B was the most common cause secondary to bacteremia (about 80% of cases) and remains so in nonimmunized populations. | |
Streptococcus pneumoniae | |
Moraxella catarrhalis Hint: See B for explanation | |
Staphylococcus aureus Hint: The most common pathogens associated with external foci (trauma) are Staphylococcus aureus and Streptococcus pyogenes, but these are seldom isolated from the blood | |
Pseudomonas aeruginosa Hint: See B for explanation |
Question 2 Explanation:
Periorbital and orbital cellulitis may be caused by trauma (e.g., a wound, an insect bite), an associated infection (e.g., sinusitis), or seeding from bacteremia. Before widespread immunization, Haemophilus influenzae type B was the most common cause secondary to bacteremia (about 80% of cases) and remains so in nonimmunized populations. Streptococcus pneumoniae accounted for most of the remaining 20% of cases. S. pneumoniae is the most likely agent in Haemophilus influenzae type B-vaccinated patients when sinusitis is present. The most common pathogens associated with external foci (trauma) are Staphylococcus aureus and Streptococcus pyogenes, but these are seldom isolated from the blood. In general, a bacterial pathogen is isolated from the blood in < 33% of patients with periorbital cellulitis.
Question 3 |
A 9-year-old boy with a week of sinus congestion now has fever, swollen red left upper and lower eyelids, and pain when he moves his left eye. His left eye bulges forward, and upward gaze is limited. Which of the following is the most appropriate management?
Oral amoxicillin-clavulanate and follow-up in 48 hours Hint: Oral antibiotics fit preseptal (periorbital) cellulitis, with no proptosis or painful eye movements. | |
Warm compresses and erythromycin eye ointment Hint: Compresses and ointment treat a stye or blepharitis, not a deep orbital infection. | |
Hospital admission and IV broad-spectrum antibiotics | |
Topical corticosteroid drops Hint: Steroid drops don't treat infection. | |
Observation, since it will clear with the sinus infection Hint: Untreated orbital cellulitis can cause vision loss and spread to the brain. |
Question 3 Explanation:
Proptosis, pain with eye movement and limited eye movement mean the infection is behind the orbital septum: orbital cellulitis. It needs hospital admission and IV broad-spectrum antibiotics right away to protect the optic nerve and stop spread to the cavernous sinus, meninges and brain. Sinusitis is the usual source, and surgery may be needed to drain an abscess.
There are 3 questions to complete.
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References: Merck Manual · UpToDate