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Orbital Infections Workup

  • Author: Keith A Lafferty, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
Updated: Jul 02, 2014

Laboratory Studies

See the list below:

  • 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

Imaging Studies

See the list below:

  • 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.[16]
    • 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.
    • Consider CT venography to evaluate the possibility of CST and the overall contiguity of the cavernous sinus.
  • 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.[17]
    • 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.[18]
    • 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.[19]
  • Ultrasonography of the orbit can miss posterior abscesses and is best used for evaluation of the globe itself (lens, vitreous, retina, and optic disc). As stated earlier, this modality may be used more frequently in evaluating the presence or absence of papilledema.

Other Tests

See the list below:

  • 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 noninfectious 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
Contributor Information and Disclosures

Keith A Lafferty, MD Adjunct Assistant Professor of Emergency Medicine, Temple University School of Medicine; Medical Student Director, Department of Emergency Medicine, Gulf Coast Medical Center

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

Disclosure: Nothing to disclose.


Keisha Bonhomme, MD Resident Physician, Department of Internal Medicine, St Vincent’s Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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 Professor, 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 Oncology Association of Practices, Southern Clinical Neurological Society, Wilderness Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Palmetto Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, South Carolina Medical Association, Columbia Medical Society, South Carolina College of Emergency Physicians, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Chief Editor for Medscape.

Additional Contributors

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, American Medical Informatics Association, Medical Association of Georgia

Disclosure: Nothing to disclose.


Robert G Hendrickson, MD Associate Professor of Emergency Medicine, Oregon Health and Science University School of Medicine; Attending Physician, Medical Director, Emergency Management Program, Department of Emergency Medicine, Oregon Health and Science University Hospital and Health Systems; Associate Medical Director, Director, Fellowship in Medical Toxicology, Disaster Preparedness Coordinator, Oregon Poison Center; Clinical Toxicologist, Alaska Poison Center and Guam Poison Center

Robert G Hendrickson, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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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.
Lamina papyracea.
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