eMedicine Specialties > Emergency Medicine > Ophthalmology

Periorbital Infections

Author: R Gentry Wilkerson, MD, Clinical Assistant Professor, Department of Emergency Medicine, State University of New York-Downstate; Attending Physician, Department of Emergency Medicine, Kings County Hospital
Coauthor(s): Richard 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; 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; Elizabeth Fiedler, MD, Clinical Instructor, Department of Emergency Medicine, Montefiore Medical Center - Weiler Division
Contributor Information and Disclosures

Updated: Nov 18, 2008

Introduction

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.

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 caused by bacteria that colonize the base of the eyelashes. If the pilosebaceous glands of Zeiss and Moll become infected an abscess will 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 an oily 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.
  • Dacryoadenitis associated with inflammation and swelling of the salivary glands is called Mikulicz syndrome. This is considered a subtype of Sjögren syndrome.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; usually, it is chronic.
  • It may also be iatrogenic after instrumentation or placement of silicone plugs in the treatment of dry eyes7

Sex

No gender predominance exists.

Age

Periorbital cellulitis is predominantly a pediatric disease.8

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

Blepharitis affects primarily older persons, with a mean age of 50 years.

Clinical

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 sensation10
    • 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.
  • 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

Physical

  • Periorbital cellulitis
    • Erythema, swelling, and tenderness of the lids without evidence of orbital congestion (proptosis, decreased extraocular movement)
    • 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.11
    • 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 whitening of the lash, may occur.3
    • If associated with ocular rosacea, telangiectatic vessels may be noted on the lid margins and cheeks.12
    • In chronic cases, ulceration of the lid, lid notching (tylosis), thinning of eyelashes (madarosis), or misdirection of the eyelashes (trichiasis) may be noted.
  • Posterior blepharitis 
    • Decreased Schirmer score
    • Conjunctival hyperemia13
  • Dacryoadenitis
    • Soft tissue swelling that is greatest at the lateral portion of the upper lid margin14
    • Deforms the upper lid into a characteristic S-shape9
    • If caused by a viral infection, the area is modestly tender. Bacterial causes result in more severe tenderness.15
    • Decreased Schirmer score
  • Dacryocystitis: Pressure on the area overlying the lacrimal sac may cause expression of purulent material from the lacrimal puncta.
  • Canaliculitis
    • Edematous, "pouting" punctum
    • Erythema of adjacent conjunctiva
    • Mucous regurgitation from punctum on application of pressure
    • Yellowish concretions may be expressed from the punctum. These are sulfur granules produced by Actinomyces israelii.

Causes

  • Periorbital cellulitis16
    • When associated with trauma
      • Staphylococcus aureus: This may include methicillin-resistant Staphylococcus aureus17 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.8,18,19,20
    • Other unusual causes 
      • Neisseria gonorrhoeae21
      • Neisseria meningitidis22,23
      • Vaccinia virus24 in a laboratory worker has been reported. Autoinoculation in patients receiving the vaccine has been reported.25
      • Herpes simplex virus
      • Mycobacterium tuberculosis26
      • Bacillus anthracis27
  • Blepharitis
    • Anterior blepharitis
      • Almost exclusively caused by Staphylococcus species3
      • Other bacteria include Propionibacterium acnes and Moraxella species.9
      • Helicobacter pylori is associated with blepharitis; however, cause and effect has not been established.28
      • Viruses - Herpes simplex virus, herpes zoster virus, and human papillomavirus
      • Mites -Demodex folliculorum and Demodex brevis29
      • Lice -Phthirus pubis causing the condition known as phthiriasis palpebrarum30
      • Noninfectious entities such as ocular rosacea and seborrheic dermatitis may also cause anterior blepharitis.
    • Posterior blepharitis - Meibomian gland dysfunction
  • 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.31
  • 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 78% (Staphylococcus and Streptococcus species) and gram-negative isolates in 22%.32
  • 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,33 Arcanobacterium (previously Corynebacterium) haemolyticum, and Mycobacterium chelonae.34
    • Iatrogenic - Instrumentation or plugging

More on Periorbital Infections

Overview: Periorbital Infections
Differential Diagnoses & Workup: Periorbital Infections
Treatment & Medication: Periorbital Infections
Follow-up: Periorbital Infections
References
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References

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Further Reading

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Keywords

periorbital infection, periorbital cellulitis, preseptal cellulitis, blepharitis, eyelid inflammation, lacrimal gland inflammation, hordeolum, stye, dacryoadenitis, dacryocystitis, canaliculitis

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Contributor Information and Disclosures

Author

R Gentry Wilkerson, MD, Clinical Assistant Professor, Department of Emergency Medicine, State University of New York-Downstate; Attending Physician, Department of Emergency Medicine, Kings County Hospital
R Gentry Wilkerson, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Richard 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 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.

Medical Editor

Edmond A Hooker II, MD, DrPH, FAAEM, Assistant Professor, Department of Health Services Administration, Xavier University; Associate Clinical Professor, Department of Emergency Medicine, University of Louisville; Assistant Clinical Professor, Department of Emergency Medicine, Wright State University
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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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.

CME Editor

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

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

 
 
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