Orbital cellulitis
Ophthalmic emergency, infection of soft tissues behind orbital septum
- extension of infection from periorbital structures (ethmoid sinusitis), face, globe, lacrimal sac or dental infection
- direct inoculation of orbit from trauma
- haematogenous spread from distant bacteraemia
Pathogens: Streptococcus pneumoniae, Staphylococcus aureus, Streptococcus pyogenes and Haemophilus influenzae
Unilateral, rapid onset of erythema and swelling, severe pain, blurred vision and diplopia
Systemic features: fever, headache, malaise.
Signs
- lid erythema and oedema
- reduced periorbital sensation
- pain
- reduced visual acuity
- proptosis (laterally and downwards)
- painful ophthalmoplegia and optic neuropathy
CT of sinuses, orbit and brain if intracranial abscess suspected
Staging:
- Stage I: preseptal cellulitis
- Stage II: orbital cellulitis
- Stage III: subperiosteal abscess
- Stage IV: orbital abscess
- Stage V: cavernous sinus thrombosis and infection
Management
- Preseptal cellulitis: oral co-amoxiclav for 10 days, drain lid abscesses
- Orbital cellulitis: hospital admission under the ophthalmology and ENT
- IM or IV antibiotics (ceftriaxone with flucloxacillin) and metronidazole (>10, chronic sino-nasal disease)
- Optic nerve function: monitored every 4 hours
- Treatment lasts 7-10 days
- Surgery: CT evidence of orbital collection, no response, visual acuity decreases, atypical picture
- Complications: exposure keratopathy, raised intraocular pressure, central retinal artery/vein occlusion, endophthalmitis, optic neuropathy, orbital abscess, meningitis, brain abscess and cavernous sinus thrombosis.