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The Swollen Eye

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									Periorbital and Orbital
       Morning Report
        August 2005
          Orbital Septum
Key to understanding the difference
between periorbital and orbital cellulitis
Impervious barrier to spread of infection
to the orbit
Infection anterior to orbital septum =
Preseptal or Periorbital cellulitis
Infection posterior to orbital septum =
Postseptal or Orbital cellulitis
         Preseptal Cellulitis
Infection does not respect the orbital septum
because it is anterior to this structure and runs
freely above or below the orbital rim
Infection occurs in 3 settings:
– Secondary to localized infection or inflammation
– Secondary to hematogenous dissemination of
  nasopharyngeal pathogens to the periorbital tissue
– Manifestation of inflammatory edema in acute
  sinusitis due to venous obstruction
Lids are crusted and thickened
Conjunctiva are hyperemic
Mucopurulent discharge often present
Haemophilus influenzae (nontypeable)
Streptococcus pneumoniae
Adenovirus (age > 6)
Associated OM in 25% with bacterial
Topical therapy with polymyxin-bacitracin,
trimethoprim-polymyxin B, ofloxacin
Stye = External hordeolum
Bacterial infection of sebaceous and sweat
glands/hair follicle on eyelid
Localized infection
Points to the lid margin as a pustule
Lid swelling and erythema
Usual cause is Staphylococcus aureus
Resolve spontaneously in up to a week
    Hordeolum vs. Chalazion

Internal Hordeolum = bacterial infection of a
meibomian gland whose orifice is at the lid margin
Chalazion = persistent, nontender, localized bulge or
nodule in the lid, overlying skin is normal; sterile
lipogranulomatous reaction
Infection of the lacrimal gland
Sudden onset of soft-tissue swelling
maximal over the outer portion of the
upper lid margin
Constitutional symptoms are common
Bacterial = extremely tender
Viral = less tender
Bacterial infection of the lacrimal sac
Rare bacterial complication of a viral URI
Infants < 3months affected due to delayed
opening, secretions, anatomy
After few days of fever, impressive erythema,
swelling and exquisite tenderness develops
Purulent material can be expressed from lacrimal
puncta, should be cultured
Commonly caused by gram-positive cocci
Most require inpatient hospitalization
         Local Skin Trauma
Preseptal cellulitis may result from secondary
bacterial infection of sites of local skin trauma
(insect bites)
Loosely bound soft tissues permit impressive
Erythema, textural changes, intense swelling,
Bacteremia is rare
Causative organisms are S aureus or group A
Bacteremic Periorbital Cellulitis
Most often in infants < 18 months
Preceding URI
Acute onset and rapid progression of
eyelid swelling; obscure eyeball
Erythematous or violaceous
Periorbital tissues nontender
EOMI and no proptosis
If inadequate exam -> Orbital CT
Bacterial Periorbital Cellulitis

Pre HIB vaccine, H influenzae type B was
causative organism in 80% of cases
S pneumoniae accounted for 20%
Hematogenous dissemination from a portal of
entry in nasopharynx
Rarely arises from paranasal sinus cavities
Parenteral therapy required with advanced
generation cephalosporin until improved
Oral antimicrobial therapy x 10 day course
Inflammatory Edema of Sinusitis
 Bacterial infection is confined to sinuses
 Sympathetic effusion as a form of preseptal
 Gradual evolution of lid swelling
 Venous drainage is impeded
 Globe is not displaced, EOMI
 Blood and tissue cultures negative
 S pneumoniae, H influenzae, M Catarrhalis
 PO trial of antibiotics if non-toxic; + follow up
Orbital cellulitis is rare
High risk of severe ocular and neurological
complications make early diagnosis and
adequate therapy essential
Complications include meningitis,
thrombophlebitis, empyema
Pathogenesis is sinusitis
Infections behind the orbital septum such
as subperiosteal abscess, orbital abscess,
cavernous sinus thrombosis,
panophthalmitis, endophthalmitis
All labeled “orbital cellulitis”
Sudden onset of erythema and swelling
Proptosis (displaced anteriorly and down),
impaired EOM, loss of visual acuity and
elevated WBC are present
Most involve formation of subperiosteal abscess
from ethmoiditis and ethmoid osteitis in young
children, whereas it results from frontal sinusitis
in adolescents
Ethmoid bone (lamina papyracea) is often
Rarely, it evolves by direct spread from the
ethmoid sinus to the orbit via bony dehiscences
in the bones of the orbit
CT Scan Recommended in the evaluation of
 children with periorbital inflammation in
 whom, proptosis, ophthalmoplegia, or loss
 of visual acuity develops, or in whom
 severe eyelid edema prevents adequate
 eye examination.
Pediatrics 1978
Orbital CT
Reveals evidence of unilateral or bialteral
sinusitis, particularly involving the
adjacent sinus
Helps differentiate presence of
subperiosteal abscess, orbital abscess that
may need draining
Right-sided proptosis
Stranding of fat
medial to right medial
rectus muscle
Subperiosteal fluid collection
Right medial rectus enlargement c/w myositis
Periorbital soft tissue swelling
B/L maxillary sinuses, ethmoid air cells opacified
Presence of a large well-defined abscess,
complete ophthalmoplegia, or impairment
of vision = surgical drainage of the
Intranasal approach, endoscopy
CULTURE material from sinuses
No abscess, only inflammatory tissue
manage with IV antibiotics
Thick, tenacious, purulent debris in
bilateral ethmoid sinuses
Thin purulent material in bilateral
maxillary sinuses
Cultures from bilateral ethmoid and
bilateral maxillary sinuses grew…
        Group A Streptococcus

         Secondary to Bilateral
Maxillary Sinusitis and Ethmoid Sinusitis
         Group A Streptococcus
Staph aureus
Strep pyogenes (group A)
anaerobic bacteria of upper resp tract
(bacteroides, prevotella, fusobacterium,
Strep pneumoniae, H influenzae, M
Catarrahalis associated with sinusitis
Cultures guide consideration for additional
antibiotic therapy
Guide therapy accordingly and maintain IV
therapy until patient examination is
Oral antibiotic therapy to complete 3 week
course of treatment
     PERIORBITAL                 ORBITAL
      CELLULITIS                CELLULITIS
Trauma or bacteremia      Sinusitis

Age 21 months             Age 12 years

Periorbital warmth,       Proptosis,
erythema, tenderness,     opthalmoplegia, visual
induration                acuity

                          Strep pnemo, H. flu, M.
Staph A, group A Strep,
                          caterhalis, group A
Strep pneumo
                          Strep, Staph A

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