Periorbital Infections 

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

Background

Periorbital infections comprise a group of infections that can be broadly classified into two distinct groups. One group consists of infections of the dermis and associated tissues around the eyes. The other group consists of infections of the lacrimal system.

Infections of the superficial skin around the eyes are called periorbital or preseptal cellulitis. These infections are limited to the area anterior to the orbital septum. The orbital septum is a fibrous membrane that extends from the periosteum of the orbit as the arcus marginalis and lies just deep to the orbicularis oculi muscle. In the upper lids, the septum fuses with the levator aponeurosis. In the lower lids, the septum fuses with the capsulopalpebral fascia.[1] The orbital septum acts as a physical barrier to the spread of infection.

Infections of the lacrimal system are classified based on the location of the infection. The lacrimal system includes the structures involved in production and drainage of tears. The lacrimal gland is located in the lateral upper lid margin. It produces about 10 mL of secretions per day. In the process of blinking, the eyes close from lateral edge to the medial edge pushing the tear film across the surface of the eye. Most of the tear volume is lost by evaporation. A small portion is drained from the lacrimal lake located at the inner canthus through the puncta and into the superior and inferior canaliculi. Tears then flow into the common canaliculus and lacrimal sac. The lacrimal duct, which lies within the bone, connects the lacrimal sac with the eventual site of egress, the inferior meatus of the nose.[1]

Blepharitis is an inflammation of the lid margins. Anterior blepharitis affects the area of the lid where the eyelashes attach. Posterior blepharitis affects the inner portion of the eyelid margin that is in contact with the eye.

Dacryoadenitis is inflammation of the lacrimal gland. Dacryocystitis is inflammation of the lacrimal duct or sac. Canaliculitis is inflammation of the canaliculi.

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Pathophysiology

Periorbital cellulitis

Periorbital cellulitis can occur by several mechanisms.

  • Infection as a result of local trauma including insect bites
  • Infection as a result of spread from contiguous structures such as in conjunctivitis, hordeolum, lacrimal system infections, and impetigo
  • Infections secondary to hematogenous spread during bacteremia due to nasopharyngeal pathogens
  • Infections secondary to sinusitis causing venous and lymphatic congestion: The sinusitis may be of odontogenic origin.[2] A thorough examination of dentition may be warranted.

Blepharitis

  • Anterior blepharitis is usually secondary to infection, seborrheic in nature, or a combination of the two. If the pilosebaceous glands of Zeiss and Moll become infected an abscess may occur. This abscess is known as an external hordeolum or stye.[3] Cell-mediated immunologic mechanisms have been implicated in the development of chronic blepharitis.[4]
  • Posterior blepharitis is caused by Meibomian gland dysfunction. The Meibomian gland secretes the oily layer of the tear film. This oily layer is responsible for preventing excessive evaporation of the aqueous layer of the tear film. If the secretions become inspissated, causing plugging of the gland, a chalazion may develop. A chalazion is a noninfectious granulomatous reaction. If there is infection secondary to plugging, an internal hordeolum develops.[5]

Dacryoadenitis

  • Dacryoadenitis is caused by local infection of the lacrimal gland by bacteria or viruses.
  • Chronic dacryoadenitis associated with inflammation and swelling of the salivary glands of unknown origin is called Mikulicz disease. When associated with other entities such as tuberculosis, sarcoidosis, or lymphoma, it is termed Mikulicz syndrome. This was previously considered a subtype of Sjögren syndrome, although now differences between the two entities have been determined.[6]

Dacryocystitis

  • Dacryocystitis is caused by inflammation of the lacrimal sac; this usually occurs in the setting of obstruction of the lacrimal apparatus.
  • The obstruction may be congenital, secondary to infection, tumor, or trauma.[1]

Canaliculitis

  • Canaliculitis is caused by infection of the canaliculi; often, it is chronic.
  • It may also be iatrogenic after instrumentation or placement of silicone plugs in the treatment of dry eyes.[7]
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Epidemiology

Sex

No gender predominance exists.

Age

Periorbital cellulitis is predominantly, although not exclusively, a pediatric disease.[8]

Obstructed lacrimal ducts causing dacryocystitis are common in infants and usually resolve by age 9-12 months.[9]

Blepharitis primarily affects older persons, with a mean age of 40-50 years.[10]

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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.

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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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