Orbital Infections Workup

  • Author: Keith A Lafferty, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Oct 31, 2011
 

Laboratory Studies

  • Complete blood count (CBC) with differential
  • Blood cultures
    • Recent literature shows a yield of 0-2% in patients with orbital cellulitis and may not be indicated in the immunized patient.
    • Minimally invasive culture techniques such as nasal swabs or eye discharge cultures yield a higher percentage of positive cultures than do blood cultures.
    • Elevated serum glucose level
  • Ketoacidosis or electrolyte abnormalities should be rapidly corrected.
  • Arterial blood gas (ABG) in debilitated patients or in patients with elevated blood glucose level
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Imaging Studies

  • CT scan - Orbit, sinuses, and frontal lobe
    • CT scan is an easily available, cost-effective investigational modality that can immediately provide images of the orbit, sinus, and head for every patient showing signs of orbital involvement. Of note, recent literature shows that the radiation exposure of routine CT scans may increase the prevalence of cancer-induced mortality over a lifetime to 0.1%. New recommendations are to keep the radiation doses as low as possible, especially in the pediatric patient.[8]
    • If a brain abscess is suspected or if the patient has HIV, consider a head CT scan to exclude mass lesions before performing a lumbar puncture (LP).
    • Contrast is generally required because of the surrounding bony structures of the orbital apex artifacts that may be encountered.
  • MRI: Although CT scanning is the predominant initial investigation of choice, MRI is superior in evaluating the soft tissues of the orbit because the resolution allows for better differentiation of diseased from normal tissue, specifically it allows one to identify intracranial dissemination of infection or cerebral infarction.
    • MRI improves visualization of cavernous sinus thrombosis.[9]
    • Contrast-enhanced orbital MRI (specifically gadolinium-based intravenous contrast) has been used in recent years to assess the extent of ophthalmological disease when there is a high index of suspicion for visual compromise secondary to disseminated infection.[10]
    • MRV can be used to noninvasively evaluate flow in the cavernous sinus and shows a filling effect in patients with CST.
    • MRI diffusion-weighted imaging (DWI) is a relatively new technique that uses discrepancies in the diffusion properties of tissue water molecules to discriminate orbital infections from hematomas, tumors, or ischemia/infarction. In a retrospective study by Sepahdari et al, DWI was shown to improve diagnostic confidence when other contrast-enhanced images (ie, T1-weighted contrast-enhanced images with fat-suppression) are equivocable. DWI has been suggested to be helpful in providing confirmation of intracranial extension of orbital abscesses and in the diagnosis of CST.[11]
  • B-scan ultrasonography of the orbit can miss posterior abscesses and is best used for evaluation of the globe itself (lens, vitreous, and retina).
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Other Tests

  • Fiberoptic nasopharyngeal endoscopy: If any suspicion of mucormycosis (ie, elevated blood glucose, leukemia, renal disease, deferoxamine therapy) exists, fiberoptic nasopharyngeal endoscopy should be performed (usually, by an otolaryngologist) to seek evidence of black eschar formation.
  • Slit-lamp examination to rule out endophthalmitis and other non-infectious causes of proptosis
  • Rapid plasma reagin (RPR), particularly in cases of insidious onset or with a history of syphilis
  • In clinical examinations suggestive of meningitis, cerebrospinal fluid (CSF) analysis for Gram stain, cell count, cultures, and antigens
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Contributor Information and Disclosures
Author

Keith A Lafferty, MD  Adjunct Assistant Professor of Emergency Medicine, Temple University; Consulting Staff, Department of Emergency Medicine, South West Regional Medical Center

Keith A Lafferty, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association, and Pennsylvania Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Keisha Bonhomme  Ross University School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Eric M Kardon, MD, FACEP  Attending Emergency Physician, Georgia Emergency Medicine Specialists; Physician, Division of Emergency Medicine, Athens Regional Medical Center

Eric M Kardon, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians

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

Eric L Weiss, MD, DTM&H  Medical Director, Office of Service Continuity and Disaster Planning, Fellowship Director, Stanford University Medical Center Disaster Medicine Fellowship, Chairman, SUMC and LPCH Bioterrorism and Emergency Preparedness Task Force, Clinical Associate Progressor, Department of Surgery (Emergency Medicine), Stanford University Medical Center

Eric L Weiss, MD, DTM&H is a member of the following medical societies: American College of Emergency Physicians, American College of Occupational and Environmental Medicine, American Medical Association, American Society of Tropical Medicine and Hygiene, Physicians for Social Responsibility, Southeastern Surgical Congress, Southern Association for Oncology, Southern Clinical Neurological Society, and Wilderness Medical Society

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Robert G Hendrickson, MD, to the development and writing of this article.

References

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  10. Parmar H, Gandhi D, Mukherji, SK, Trobe JD. Restricted Diffusion in the Superior Ophthalmic Vein and Cavernous Sinus in a Case of Cavernous Sinus Thrombosis. J Neuro-Ophthalmol. 2009;29;1:16-20. [Medline].

  11. Sepahdari AR, Aakalu VK, Kapur R, Michals EA, Saran N, French A, et al. MRI of orbital cellulitis and orbital abscess: the role of diffusion-weighted imaging. AJR Am J Roentgenol. Sep 2009;193(3):W244-50. [Medline].

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Complications of orbital infections. Brain abscess in a young man secondary to an orbital infection from Mucor species.
Orbital infections. Orbital abscess with significant proptosis.
Orbital infections. Subperiosteal abscess with contiguous sinusitis.
Orbital infections. Subperiosteal abscess with contiguous sinusitis.
Orbital infections. Frontal sinusitis.
Orbital infections. Orbital abscess with significant proptosis.
Cavernous sinus and its cranial nerves.
Orbital cellulitis; chemosis.
 
 
 
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