Periorbital Infections Clinical Presentation

  • Author: R Gentry Wilkerson, MD; Chief Editor: Robert E O'Connor, MD, MPH   more...
 
Updated: Jul 10, 2011
 

History

  • Periorbital cellulitis
    • An antecedent history of insect bite, trauma to the periorbital skin, infection of adjacent structures, upper respiratory infection, or sinusitis may be present.
    • A sudden increase in temperature and rapid swelling of tissue may occur.
    • A history of underlying illness (eg, HIV, acute lymphoblastic leukemia), which would increase the patient's risk of infection, may be present.
  • Anterior blepharitis
    • Erythema, pruritus, and crusting of lid margins
    • Typically without discharge
  • Posterior blepharitis
    • Epiphora
    • Foreign body or burning sensation[11]
    • Blurred vision, photophobia
  • Dacryoadenitis
    • Swelling of upper lateral eyelid
    • Scleral injection
    • If caused by a viral infection, the area is modestly tender. Bacterial causes result in more severe tenderness.[5]
  • Dacryocystitis
    • A history of chronic conjunctivitis or recent upper respiratory infection may be present.
    • Epiphora
    • Fever
    • Swelling, tenderness, and erythema usually localized of the medial canthal area
    • Purulent discharge
  • Canaliculitis
    • Epiphora
    • Irritation or pruritus of medial portion of affected eyelid
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Physical

  • Periorbital cellulitis
    • Erythema, swelling, and tenderness of the lids without evidence of orbital congestion (proptosis, decreased extraocular movement), as depicted in the image below Preseptal cellulitis. This image shows an 8-year-oPreseptal cellulitis. This image shows an 8-year-old patient who presented with unilateral eyelid swelling and erythema.
    • Fever
    • Vesicles if associated with herpetic infection
    • Violaceous discoloration of the lid is more commonly associated with Haemophilus influenzae but may be associated with infection with Streptococcus pneumoniae.[12]
    • If associated with trauma, there may be a break in the skin overlying the area of cellulitis.
  • Anterior blepharitis
    • Crusting at the base of the lash (known as scurf or collarettes), erythema of lid
    • Usually, no discharge
    • Poliosis, or depigmentation of the lash, may occur.[3]
    • If associated with ocular rosacea, telangiectatic vessels may be noted on the lid margins and cheeks.[13]
    • In chronic cases, ulceration of the lid, lid notching (tylosis), thinning of eyelashes (madarosis), or misdirection of the eyelashes (trichiasis) may be noted.[14]
  • Posterior blepharitis
    • Decreased Schirmer score
    • Conjunctival hyperemia[15]
  • Dacryoadenitis
    • Soft tissue swelling that is greatest at the lateral portion of the upper lid margin[16]
    • Deforms the upper lid into a characteristic S-shape[9]
    • If caused by a viral infection, the area is modestly tender. Bacterial causes result in more severe tenderness.[5]
    • Decreased Schirmer score
  • Dacryocystitis: Application of pressure to the area overlying the lacrimal sac may cause expression of purulent material from the lacrimal puncta. Dacryocystitis is shown in the image below. Acute dacryocystitis. Acute dacryocystitis.
  • Canaliculitis
    • Edematous, "pouting" punctum
    • Erythema of adjacent conjunctiva
    • Mattering of the eyelid
    • Mucous regurgitation from punctum on application of pressure
    • Yellowish concretions may be expressed from the punctum. These are sulfur granules produced by Actinomyces israelii.
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Causes

Periorbital cellulitis [17]

  • When associated with trauma
    • Staphylococcus aureus: This may include methicillin-resistant Staphylococcus aureus[18] and treatment should be tailored to local incidence of infection .
    • Streptococcus pyogenes (group A streptococci)
  • In the absence of trauma
    • Streptococcus pneumoniae
    • H influenzae type b was the predominant cause prior to the advent of the Hib vaccine but has now only been shown to cause rare cases.[8, 19, 20, 21]
  • Other unusual causes
    • Neisseria gonorrhoeae[22]
    • Neisseria meningitidis[23, 24]
    • Vaccinia virus[25] in a laboratory worker has been reported. Autoinoculation in patients receiving the vaccine has been reported.[26]
    • Herpes simplex virus
    • Mycobacterium tuberculosis[27]
    • Bacillus anthracis[28]
    • Secondary to orbital cysticercosis caused by Taenia solium[29]

Blepharitis

  • Anterior blepharitis
    • Infectious etiology usually due to Staphylococcus species.[3]
    • Other bacteria include Propionibacterium acnes,Moraxella species, and Corynebacterium species.[9, 14]
    • Helicobacter pylori is associated with blepharitis; however, cause and effect has not been established.[30]
    • Viruses - Herpes simplex virus, herpes zoster virus, and human papillomavirus
    • Mites -Demodex folliculorum and Demodex brevis[31]
    • Lice -Phthirus pubis causing the condition known as phthiriasis palpebrarum[32]
    • Noninfectious entities such as ocular rosacea and seborrheic dermatitis also cause anterior blepharitis.
  • Posterior blepharitis - Meibomian gland dysfunction leading to increased evaporation of the protective tear layer.[33]
    • Most frequently associated with rosacea.
    • Pityrosporum fungal infection is associated with Meibomian gland dysfunction.[34]

Dacryoadenitis

  • Bacteria - This is most often caused by gram-positive cocci, usually staphylococci. It may also be caused by Streptococcus pneumoniae.
  • Viruses - Prior to increased immunization rates, the mumps virus was most often implicated. Now, the Epstein-Barr virus is most often associated with chronic dacryoadenitis.[35]

Dacryocystitis

  • Dacryocystitis usually occurs as a result of obstruction of the lacrimal system, which may be congenital, infectious, tumor, inflammatory, or traumatic.
  • Infectious causes include most commonly gram-positive isolates in 71-78% (Staphylococcus and Streptococcus species) and gram-negative isolates in 22-29%.[36, 37]
  • Rarely, it may be the result of mucormycosis.[38]

Canaliculitis

  • It is classically taught that the most common pathogens of canaliculitis are Actinomyces israelii and Nocardia (formerly known as Streptothrix) species.[9]
  • Recent case reviews have shown mixed flora associated with infection. Species isolated include Staphylococcus species, Escherichia coli, Haemophilus species, Pseudomonas aeruginosa, Klebsiella oxytocia,[39]Arcanobacterium (previously Corynebacterium) haemolyticum,[40] and Mycobacterium chelonae.[41]
  • Cases may be polymicrobial.[42]
  • Iatrogenic - Instrumentation or plugging
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Contributor Information and Disclosures
Author

R Gentry Wilkerson, MD  Assistant Professor, Director of Research, Emergency Medicine Residency Program, University of South Florida College of Medicine, Tampa General Hospital

R Gentry Wilkerson, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Richard H Sinert, DO  Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Zach Kassutto, MD, FAAP  Director, Pediatric Emergency Medicine, Capital Health System; Associate Professor of Pediatrics and Emergency Medicine, Drexel University College of Medicine; Attending Physician, St Christopher's Hospital for Children

Zach Kassutto, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Elizabeth Fiedler, MD  Clinical Instructor, Department of Emergency Medicine, Montefiore Medical Center - Weiler Division

Elizabeth Fiedler, MD is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Edmond A Hooker II, MD, DrPH, FAAEM  Assistant Professor, Department of Emergency Medicine, University of Cincinnati College of Medicine

Edmond A Hooker II, MD, DrPH, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Public Health Association, Society for Academic Emergency Medicine, and Southern 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

Douglas Lavenburg, MD  Clinical Professor, Department of Emergency Medicine, Christiana Care Health Systems

Douglas Lavenburg, MD is a member of the following medical societies: American Society of Cataract and Refractive Surgery

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

Robert E O'Connor, MD, MPH  Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

References

  1. Yanoff. Ophthalmology [MD Consult]. 2nd ed. 2004:chap 82, 98.

  2. Brook I. Microbiology of acute sinusitis of odontogenic origin presenting with periorbital cellulitis in children. Ann Otol Rhinol Laryngol. May 2007;116(5):386-8. [Medline].

  3. Noble. Textbook of Primary Care Medicine [MD Consult]. 3rd ed. 2001:1693.

  4. Rubin M, Rao SN. Efficacy of topical cyclosporin 0.05% in the treatment of posterior blepharitis. J Ocul Pharmacol Ther. Feb 2006;22(1):47-53. [Medline].

  5. Wald ER. Periorbital and orbital infections. Infect Dis Clin North Am. Jun 2007;21(2):393-408, vi. [Medline].

  6. Lee S, Tsirbas A, McCann JD, et al. Mikulicz's disease: a new perspective and literature review. Eur J Ophthalmol. Mar-Apr 2006;16(2):199-203. [Medline].

  7. Lee J, Flanagan JC. Complications associated with silicone intracanalicular plugs. Ophthal Plast Reconstr Surg. Nov 2001;17(6):465-9. [Medline].

  8. Givner LB, Mason EO Jr, Barson WJ, et al. Pneumococcal facial cellulitis in children. Pediatrics. Nov 2000;106(5):E61. [Medline].

  9. Gershon. Krugman's Infectious Diseases of Children. 11th ed. 2004:(MD Consult) [pg 163-4].

  10. Chin RL. Emergency Management of Infectious Diseases. Cambridge University Press; 2008:151.

  11. Friedlaender MH. Blepharitis, allergy, and dry eye: lumpers and splitters. Ann Ophthalmol (Skokie). Spring 2006;38(1):4-5. [Medline].

  12. Thirumoorthi MC, Asmar BI, Dajani AS. Violaceous discoloration in pneumococcal cellulitis. Pediatrics. Oct 1978;62(4):492-3. [Medline].

  13. Carter SR. Eyelid disorders: diagnosis and management. Am Fam Physician. Jun 1998;57(11):2695-702. [Medline].

  14. Jackson WB. Blepharitis: current strategies for diagnosis and management. Can J Ophthalmol. Apr 2008;43(2):170-9. [Medline].

  15. Farpour B, McClellan KA. Diagnosis and management of chronic blepharokeratoconjunctivitis in children. J Pediatr Ophthalmol Strabismus. Jul-Aug 2001;38(4):207-12. [Medline].

  16. Wald ER. Periorbital and orbital infections. Pediatr Rev. Sep 2004;25(9):312-20. [Medline].

  17. Givner LB. Periorbital versus orbital cellulitis. Pediatr Infect Dis J. Dec 2002;21(12):1157-8. [Medline].

  18. Charalampidou S, Connell P, Fennell J, et al. Preseptal cellulitis caused by community acquired methicillin resistant Staphylococcus aureus (CAMRSA). Br J Ophthalmol. Dec 2007;91(12):1723-4. [Medline].

  19. Ambati BK, Ambati J, Azar N, et al. Periorbital and orbital cellulitis before and after the advent of Haemophilus influenzae type B vaccination. Ophthalmology. Aug 2000;107(8):1450-3. [Medline].

  20. Donahue SP, Schwartz G. Preseptal and orbital cellulitis in childhood. A changing microbiologic spectrum. Ophthalmology. Oct 1998;105(10):1902-5; discussion 1905-6. [Medline].

  21. Schwartz GR, Wright SW. Changing bacteriology of periorbital cellulitis. Ann Emerg Med. Dec 1996;28(6):617-20. [Medline].

  22. Green JA, Lim J, Barkham T. Neisseria gonorrhoeae: a rare cause of preseptal cellulitis?. Int J STD AIDS. Feb 2006;17(2):137-8. [Medline].

  23. Chand DV, Hoyen CK, Leonard EG, et al. First reported case of Neisseria meningitidis periorbital cellulitis associated with meningitis. Pediatrics. Dec 2005;116(6):e874-5. [Medline].

  24. Porras MC, Martínez VC, Ruiz IM, et al. Acute cellulitis: an unusual manifestation of meningococcal disease. Scand J Infect Dis. 2001;33(1):56-9. [Medline].

  25. Lewis FM, Chernak E, Goldman E, et al. Ocular vaccinia infection in laboratory worker, Philadelphia, 2004. Emerg Infect Dis. Jan 2006;12(1):134-7. [Medline].

  26. Fillmore GL, Ward TP, Bower KS, et al. Ocular complications in the Department of Defense Smallpox Vaccination Program. Ophthalmology. Nov 2004;111(11):2086-93. [Medline].

  27. Raina UK, Jain S, Monga S, et al. Tubercular preseptal cellulitis in children: a presenting feature of underlying systemic tuberculosis. Ophthalmology. Feb 2004;111(2):291-6. [Medline].

  28. Artac H, Silahli M, Keles S, et al. A rare cause of preseptal cellulitis: anthrax. Pediatr Dermatol. May-Jun 2007;24(3):330-1. [Medline].

  29. Kohli V, Gaur S, Deen M, Engel M, Shah K. Orbital cysticercosis presenting as recurrent periorbital cellulitis in a four-year-old child. Pediatr Infect Dis J. May 2010;29(5):481. [Medline].

  30. Sacca SC, Pascotto A, Venturino GM, et al. Prevalence and treatment of Helicobacter pylori in patients with blepharitis. Invest Ophthalmol Vis Sci. Feb 2006;47(2):501-8. [Medline].

  31. Kheirkhah A, Casas V, Li W, et al. Corneal manifestations of ocular demodex infestation. Am J Ophthalmol. May 2007;143(5):743-749. [Medline].

  32. Thappa DM, Karthikeyan K, Jeevankumar B. Phthiriasis palpebrarum. Postgrad Med J. Feb 2003;79(928):102. [Medline].

  33. Mathers WD, Shields WJ, Sachdev MS, Petroll WM, Jester JV. Meibomian gland dysfunction in chronic blepharitis. Cornea. Jul 1991;10(4):277-85. [Medline].

  34. Seal DV, McGill JI, Jacobs P, Liakos GM, Goulding NJ. Microbial and immunological investigations of chronic non-ulcerative blepharitis and meibomianitis. Br J Ophthalmol. Aug 1985;69(8):604-11. [Medline].

  35. Rhem MN, Wilhelmus KR, Jones DB. Epstein-Barr virus dacryoadenitis. Am J Ophthalmol. Mar 2000;129(3):372-5. [Medline].

  36. Mills DM, Bodman MG, Meyer DR, et al. The microbiologic spectrum of dacryocystitis: a national study of acute versus chronic infection. Ophthal Plast Reconstr Surg. Jul-Aug 2007;23(4):302-6. [Medline].

  37. Bharathi MJ, Ramakrishnan R, Maneksha V, Shivakumar C, Nithya V, Mittal S. Comparative bacteriology of acute and chronic dacryocystitis. Eye (Lond). Jul 2008;22(7):953-60. [Medline].

  38. Kapur R, Aakalu VK, August CZ, Weiss RA. Mucormycosis infection of the lacrimal sac. Ophthal Plast Reconstr Surg. Nov-Dec 2009;25(6):494-6. [Medline].

  39. Anand S, Hollingworth K, Kumar V, et al. Canaliculitis: the incidence of long-term epiphora following canaliculotomy. Orbit. Mar 2004;23(1):19-26. [Medline].

  40. Varma D, Chang B, Musaad S. A case series on chronic canaliculitis. Orbit. Mar 2005;24(1):11-4. [Medline].

  41. Moscato EE, Sires BS. Atypical canaliculitis. Ophthal Plast Reconstr Surg. Jan-Feb 2008;24(1):54-5. [Medline].

  42. Zaldívar RA, Bradley EA. Primary canaliculitis. Ophthal Plast Reconstr Surg. Nov-Dec 2009;25(6):481-4. [Medline].

  43. Yuen SJ, Rubin PA. Idiopathic orbital inflammation: distribution, clinical features, and treatment outcome. Arch Ophthalmol. Apr 2003;121(4):491-9. [Medline].

  44. Lamoreau KP, Fanciullo LM. Pott's Puffy Tumor Mimicking Preseptal Cellulitis. Clin Exp Opt 2007; Published early online. Accessed 15 March, 2008.

  45. Morley AM. Pott's puffy tumour: a rare but sinister cause of periorbital oedema in a child. Eye (Lond). Apr 2009;23(4):990-1. [Medline].

  46. Swann PG, Weir J. Is it blepharitis?. Clin Exp Optom. Mar 2005;88(2):113-4. [Medline].

  47. Boruchoff SA, Boruchoff SE. Infections of the lacrimal system. Infect Dis Clin North Am. Dec 1992;6(4):925-32. [Medline].

  48. Charles NC, Lisman RD, Mittal KR. Carcinoma of the lacrimal canaliculus masquerading as canaliculitis. Arch Ophthalmol. Mar 2006;124(3):414-6. [Medline].

  49. Howe L, Jones NS. Guidelines for the management of periorbital cellulitis/abscess. Clin Otolaryngol Allied Sci. Dec 2004;29(6):725-8. [Medline].

  50. Cortez O, Schaeffer CJ, Hatem SF, Glauser J, Ahmed M. Cases from the Cleveland Clinic: cerebral venous sinus thrombosis presenting to the emergency department with worst headache of life. Emerg Radiol. Jan 2009;16(1):79-82. [Medline].

  51. [Best Evidence] Rudloe TF, Harper MB, Prabhu SP, Rahbar R, Vanderveen D, Kimia AA. Acute periorbital infections: who needs emergent imaging?. Pediatrics. Apr 2010;125(4):e719-26. [Medline].

  52. Tost F, Bruder R, Clemens S. Clinical diagnosis of chronic canaliculitis by 20-MHz ultrasound. Ophthalmologica. 2000;214(6):433-6. [Medline].

  53. O'Donnell BA, Clement CI. Assessing patients with epiphora who are patent to syringing: clinical predictors of response to dacryocystorhinostomy. Ophthal Plast Reconstr Surg. May-Jun 2007;23(3):173-8. [Medline].

  54. Vu BL, Dick PT, Levin AV, et al. Development of a clinical severity score for preseptal cellulitis in children. Pediatr Emerg Care. Oct 2003;19(5):302-7. [Medline].

  55. Thikkurissy S, Rawlins JT, Kumar A, Evans E, Casamassimo PS. Rapid treatment reduces hospitalization for pediatric patients with odontogenic-based cellulitis. Am J Emerg Med. Jul 2010;28(6):668-72. [Medline].

  56. Viswalingam M, Rauz S, Morlet N, et al. Blepharokeratoconjunctivitis in children: diagnosis and treatment. Br J Ophthalmol. Apr 2005;89(4):400-3. [Medline].

  57. Yactayo-Miranda Y, Ta CN, He L, Kreutzer TC, Nentwich MM, Kampik A, et al. A prospective study determining the efficacy of topical 0.5% levofloxacin on bacterial flora of patients with chronic blepharoconjunctivitis. Graefes Arch Clin Exp Ophthalmol. Jul 2009;247(7):993-8. [Medline].

  58. American Academy of Ophthalmology. Preferred Practice Patterns: Blepharitis. Available at: http://one.aao.org. Accessed March 14, 2008.

  59. Luchs J. Efficacy of topical azithromycin ophthalmic solution 1% in the treatment of posterior blepharitis. Adv Ther. Sep 2008;25(9):858-70. [Medline].

  60. Castanheira M, Watters AA, Bell JM, Turnidge JD, Jones RN. Fusidic Acid Resistance Rates and Prevalence of Resistance Mechanisms Among Staphylococcus spp. isolated in North America and Australia (2007-2008). Antimicrob Agents Chemother. Jun 21 2010;[Medline].

  61. Knezevic T, Ivekovic R, Astalos JP, Novak Laus K, Mandic Z, Matejcic A. Botulinum toxin A injection for primary and recurrent chalazia. Graefes Arch Clin Exp Ophthalmol. Jun 2009;247(6):789-94. [Medline].

  62. Gao YY, Di Pascuale MA, Elizondo A, Tseng SC. Clinical treatment of ocular demodecosis by lid scrub with tea tree oil. Cornea. Feb 2007;26(2):136-43. [Medline].

  63. Pinckney J 2nd, Cole P, Vadapalli SP, Rosen T. Phthiriasis palpebrarum: a common culprit with uncommon presentation. Dermatol Online J. 2008;14(4):7. [Medline].

  64. Aburn NS, Sullivan TJ. Infectious mononucleosis presenting with dacryoadenitis. Ophthalmology. May 1996;103(5):776-8. [Medline].

  65. Greenberg MF, Pollard ZF. The red eye in childhood. Pediatr Clin North Am. Feb 2003;50(1):105-24. [Medline].

  66. Baylin EB, Gladstone GJ. Endoscopic lacrimal surgery. Otolaryngol Clin North Am. Oct 2005;38(5):1099-107. [Medline].

  67. Lazzeri D, Lazzeri S, Figus M, Tascini C, Bocci G, Colizzi L, et al. Periorbital Necrotizing Fasciitis. Br J Ophthalmol. Nov 5 2009;[Medline].

  68. Ataullah S, Sloan B. Acute dacryocystitis presenting as an orbital abscess. Clin Experiment Ophthalmol. Feb 2002;30(1):44-6. [Medline].

  69. American Academy of Ophthalmology. Blepharitis Fact Sheet. Accessed December 3, 2009.

  70. American Academy of Ophthalmology. Preferred Practice Patterns: Blepharitis. Accessed December 3, 2009.

 
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Preseptal cellulitis. This image shows an 8-year-old patient who presented with unilateral eyelid swelling and erythema.
Acute dacryocystitis.
 
 
 
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