Orbital Cellulitis 

  • Author: John N Harrington, MD, FACS; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Feb 9, 2012
 

Background

The orbital septum is a layer of fascia extending vertically from the periosteum of the orbital rim to the levator aponeurosis in the upper eyelid and to the inferior border of the tarsal plate in the lower eyelid. Orbital cellulitis and preseptal cellulitis are the major infections of the ocular adnexal and orbital tissues. Orbital cellulitis is an infection of the soft tissues of the orbit posterior to the orbital septum, differentiating it from preseptal cellulitis, which is an infection of the soft tissue of the eyelids and periocular region anterior to the orbital septum.

Orbital cellulitis has various causes and may be associated with serious complications. As many as 11% of cases of orbital cellulitis result in visual loss. Prompt diagnosis and proper management are essential for curing the patient with orbital cellulitis.

Examples are shown in the images below.

A male patient with orbital cellulitis with proptoA male patient with orbital cellulitis with proptosis, ophthalmoplegia, and edema and erythema of the eyelids. The patient also exhibited pain on eye movement, fever, headache, and malaise. A male patient with orbital cellulitis with proptoA male patient with orbital cellulitis with proptosis, ophthalmoplegia, and edema and erythema of the eyelids. The patient also exhibited chemosis and resistance to retropulsion of the globe.
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Pathophysiology

Orbital cellulitis occurs in the following 3 situations: (1) extension of an infection from the periorbital structures, most commonly from the paranasal sinuses, but also from the face, the globe, and the lacrimal sac; (2) direct inoculation of the orbit from trauma or surgery; and (3) hematogenous spread from bacteremia.

The medial orbital wall is thin and perforated not only by numerous blood valveless vessels and nerves but also by numerous other defects (Zuckerkandl dehiscences). This combination of thin bone, foramina for neurovascular passage, and naturally occurring defects in the bone allows for easy communication of infectious material between the ethmoidal air cells and the subperiorbital space in the medial aspect of the orbit. The most common location of a subperiorbital abscess is along the medial orbital wall. The periorbita is adherent relatively loosely to the bone of the medial orbital wall, which allows abscess material to easily move laterally, superiorly, and inferiorly within the subperiorbital space.

In addition, the lateral extensions of the sheaths of the extraocular muscles, the intermuscular septa, extend from one rectus muscle to the next and from the insertions of the muscles to their origins at the annulus of Zinn posteriorly. Posteriorly in the orbit, the fascia between the rectus muscles is thin and often incomplete allowing easy extension between the extraconal and intraconal orbital spaces.

Venous drainage from the middle third of the face, including the paranasal sinuses, is mainly via the orbital veins, which are without valves, allowing the passage of infection both anterograde and retrograde.

Infectious material may be introduced into the orbit directly from accidental or surgical trauma.

Ethmoid sinusitis is the most common cause of orbital cellulitis in all age groups and aerobic non-spore–forming bacteria are the organisms most frequently responsible.

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Epidemiology

Frequency

An increased incidence of orbital cellulitis occurs in the winter, both nationally and internationally, because of the increased incidence of sinusitis in cold weather.

United States

There is a noted increase in the frequency of orbital cellulitis due to community-acquired methicillin-resistant Staphylococcus aureus infections involved in orbital cellulitis.[1, 2, 3, 4, 5, 6, 7]

Mortality/Morbidity

Prior to the availability of antibiotics, patients with orbital cellulitis had a mortality rate of 17%, and 20% of survivors were blind in the affected eye. However, with prompt diagnosis and appropriate use of antibiotics, this rate has been reduced significantly; blindness occurs in up to 11% of cases. Orbital cellulitis due to methicillin-resistant S aureus can lead to blindness despite antibiotic treatment.

Race

No racial predilection exists for orbital cellulitis.

Sex

No frequency difference exists between the sexes in adults, except for cases of methicillin-resistant Saureus, which are more common in females than in males by a ratio of 4:1. However, in children, orbital cellulitis has been reported as twice as common in males than in females.

Age

Orbital cellulitis, in general, is more common in children than in adults.[8] Median age of children hospitalized with orbital cellulitis is 7-12 years.

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Contributor Information and Disclosures
Author

John N Harrington, MD, FACS  Director of Ophthalmic Plastic and Reconstructive Surgery, Department of Ophthalmology, Baylor University Medical Center; Clinical Professor Emeritus, Department of Ophthalmology, University of Texas Southwestern Medical Center at Dallas, Southwestern Medical School

John N Harrington, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, and Texas Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Brian A Phillpotts, MD  Former Vitreo-Retinal Service Director, Former Program Director, Clinical Assistant Professor, Department of Ophthalmology, Howard University College of Medicine

Brian A Phillpotts, MD is a member of the following medical societies: American Academy of Ophthalmology, American Diabetes Association, American Medical Association, and National Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Mark T Duffy, MD, PhD  Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic; Medical Director, Advanced Cosmetic Solutions, A BayCare Clinic

Mark T Duffy, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Sigma Xi, and Society for Neuroscience

Disclosure: Allergan - Botox Cosmetic Honoraria Speaking and teaching

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

References

  1. Anari S, Karagama YG, Fulton B, et al. Neonatal disseminated methicillin-resistant Staphylococcus aureus presenting as orbital cellulitis. J Laryngol Otol. Jan 2005;119(1):64-7. [Medline].

  2. Blomquist PH. Methicillin-resistant Staphylococcus aureus infections of the eye and orbit (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc. 2006;104:322-45. [Medline].

  3. Boden JH, Ainbinder DJ. Methicillin-resistant ascending facial and orbital cellulitis in an operation Iraqi Freedom troop population. Ophthal Plast Reconstr Surg. Sep-Oct 2007;23(5):397-9. [Medline].

  4. Hollsten J, Hollsten D, Green, MK. Orbital community-acquired methicillin-resistant Staphylococcus aureus infections: the range of presentation, increasing prevalence and efficacy of treatment. Poster at Fall Scientific Symposium, American Society of Ophthalmic Plastic and Reconstructive Surgery. Nov 2008.

  5. Rutar T, Chambers HF, Crawford JB, et al. Ophthalmic manifestations of infections caused by the USA300 clone of community-associated methicillin-resistant Staphylococcus aureus. Ophthalmology. Aug 2006;113(8):1455-62. [Medline].

  6. Rutar T, Zwick OM, Cockerham KP, et al. Bilateral blindness from orbital cellulitis caused by community-acquired methicillin-resistant Staphylococcus aureus. Am J Ophthalmol. Oct 2005;140(4):740-2. [Medline].

  7. McKinley SH, Yen MT, Miller AM, et al. Microbiology of pediatric orbital cellulitis. Am J Ophthalmol. Oct 2007;144(4):497-501. [Medline].

  8. Nageswaran S, Woods CR, Benjamin DK Jr, et al. Orbital cellulitis in children. Pediatr Infect Dis J. Aug 2006;25(8):695-9. [Medline].

  9. Grimes D, Fan K, Huppa C. Case report: dental infection leading to orbital cellulitis. Dent Update. May 2006;33(4):217-8, 220. [Medline].

  10. Babar TF, Zaman M, Khan MN, Khan MD. Risk factors of preseptal and orbital cellulitis. J Coll Physicians Surg Pak. Jan 2009;19(1):39-42. [Medline].

  11. Kloek CE, Rubin PA. Role of inflammation in orbital cellulitis. Int Ophthalmol Clin. Spring 2006;46(2):57-68. [Medline].

  12. Chiu ES, Capel B, Press R, et al. Successful management of orbital cellulitis and temporary visual loss after blepharoplasty. Plast Reconstr Surg. Sep 2006;118(3):67e-72e. [Medline].

  13. Ferry AP, Abedi S. Diagnosis and management of rhino-orbitocerebral mucormycosis (phycomycosis). A report of 16 personally observed cases. Ophthalmology. Sep 1983;90(9):1096-104. [Medline].

  14. Gass JD. Ocular manifestations of acute mucormycosis. Arch Ophthalmol. Feb 1961;65:226-37. [Medline].

  15. Sridhara SR, Paragache G, Panda NK, et al. Mucormycosis in immunocompetent individuals: an increasing trend. J Otolaryngol. Dec 2005;34(6):402-6. [Medline].

  16. Yen MT, Yen KG. Effect of corticosteroids in the acute management of pediatric orbital cellulitis with subperiosteal abscess. Ophthal Plast Reconstr Surg. Sep 2005;21(5):363-6; discussion 366-7. [Medline].

  17. Garcia GH, Harris GJ. Criteria for nonsurgical management of subperiosteal abscess of the orbit: analysis of outcomes 1988-1998. Ophthalmology. Aug 2000;107(8):1454-6; discussion 1457-8. [Medline].

  18. Emmett Hurley P, Harris GJ. Subperiosteal abscess of the orbit: duration of intravenous antibiotic therapy in nonsurgical cases. Ophthal Plast Reconstr Surg. Jan 2012;28(1):22-6. [Medline].

  19. Vayalumkal JV, Jadavji T. Children hospitalized with skin and soft tissue infections: a guide to antibacterial selection and treatment. Paediatr Drugs. 2006;8(2):99-111. [Medline].

  20. Bergin DJ, Wright JE. Orbital cellulitis. Br J Ophthalmol. Mar 1986;70(3):174-8. [Medline].

  21. Bullock JD, Fleishman JA. Orbital cellulitis following dental extraction. Trans Am Ophthalmol Soc. 1984;82:111-33. [Medline].

  22. Denning DW, Stevens DA. Antifungal and surgical treatment of invasive aspergillosis: review of 2,121 published cases. Rev Infect Dis. Nov-Dec 1990;12(6):1147-201. [Medline].

  23. Dortzbach RK, Segrest DR. Orbital aspergillosis. Ophthalmic Surg. Mar 1983;14(3):240-4. [Medline].

  24. Doxanas MT, Anderson RL. Clinical Orbital Anatomy. Baltimore, Md: Williams & Wilkins;1984.

  25. Harris GJ. Subperiosteal abscess of the orbit. Arch Ophthalmol. May 1983;101(5):751-7. [Medline].

  26. Harris GJ. Subperiosteal inflammation of the orbit. A bacteriological analysis of 17 cases. Arch Ophthalmol. Jul 1988;106(7):947-52. [Medline].

  27. Harris GJ, Will BR. Orbital aspergillosis. Conservative debridement and local amphotericin irrigation. Ophthal Plast Reconstr Surg. 1989;5(3):207-11. [Medline].

  28. Hornblass A, Herschorn BJ, Stern K, et al. Orbital abscess. Surv Ophthalmol. Nov-Dec 1984;29(3):169-78. [Medline].

  29. Jackson K, Baker SR. Clinical implications of orbital cellulitis. Laryngoscope. May 1986;96(5):568-74. [Medline].

  30. Jones DB, Steinkuller PG. Strategies for the initial management of acute preseptal and orbital cellulitis. Trans Am Ophthalmol Soc. 1988;86:94-108; discussion 108-12. [Medline].

  31. Jordan DR, St Onge P, Anderson RL, et al. Complications associated with alloplastic implants used in orbital fracture repair. Ophthalmology. Oct 1992;99(10):1600-8. [Medline].

  32. Koornneef L. Orbital septa: anatomy and function. Ophthalmology. May 1979;86(5):876-80. [Medline].

  33. Lemke BN, Gonnering RS, Weinstein JM. Orbital cellulitis with periosteal elevation. Ophthal Plast Reconstr Surg. 1987;3(1):1-7. [Medline].

  34. Mauriello JA Jr, Hargrave S, Yee S, et al. Infection after insertion of alloplastic orbital floor implants. Am J Ophthalmol. Feb 15 1994;117(2):246-52. [Medline].

  35. Schramm VL Jr, Curtin HD, Kennerdell JS. Evaluation of orbital cellulitis and results of treatment. Laryngoscope. Jul 1982;92(7 Pt 1):732-8. [Medline].

  36. Shields JA, Shields CL, Suvarnamani C, et al. Retinoblastoma manifesting as orbital cellulitis. Am J Ophthalmol. Oct 15 1991;112(4):442-9. [Medline].

  37. Steinkuller PG, Jones DB. Microbial preseptal and orbital cellulitis. In: Tasman W, ed. Clinical Ophthalmology. Philadelphia, Pa: Lippincott, Williams & Wilkins; 1999:1-8, 17-29, Chap 25.

  38. Westley GJ, Mazur JM, Sifton DW, eds. Physicians' Desk Reference. Vol 52. Montvale, NJ: Medical Economics Co; 1998:2081, 2145.

 
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A male patient with orbital cellulitis with proptosis, ophthalmoplegia, and edema and erythema of the eyelids. The patient also exhibited pain on eye movement, fever, headache, and malaise.
A male patient with orbital cellulitis with proptosis, ophthalmoplegia, and edema and erythema of the eyelids. The patient also exhibited chemosis and resistance to retropulsion of the globe.
 
 
 
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