eMedicine Specialties > Emergency Medicine > Ophthalmology

Periorbital Infections

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
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

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 meningitidis^22,23
  - 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

Differential Diagnoses

Angioedema
Bites, Insects
Cavernous Sinus Thrombosis
Chalazion
Hordeolum and Stye
Orbital Infections

Workup

Laboratory Studies

Periorbital cellulitis
- Complete blood count (CBC) with differential is not routinely necessary. It may be helpful if bacteremia or sepsis is a concern.
- Blood cultures may be performed if bacteremia or sepsis is a concern.
- Skin culture has a very low yield.
Dacryoadenitis
- CBC with differential and blood culture may be performed if bacteremia or sepsis is a concern.
- Serology testing may be indicated if a viral etiology needs to be established.
No laboratory studies are indicated for routine use in dacryocystitis, blepharitis, and canaliculitis.

Imaging Studies

Periorbital cellulitis
- Computed tomography (CT) of the orbits should be performed to rule out orbital and subperiosteal involvement and cavernous sinus thrombosis. CT also helps to distinguish sinusitis as cause.
- Indications for CT include inability to perform a full evaluation of the eye due to edema or patients with proptosis, ophthalmoplegia, decreased visual acuity or color vision, bilateral periorbital edema, or central symptoms.⁴⁰
- CT will show lid edema but no proptosis or "streaking" of the orbital fat, which lies posterior to the orbital septum.
- MRI is the study of choice to rule out cavernous sinus thrombosis.
- Patients whose condition fails to improve after 24-36 hours of appropriate antimicrobial therapy should also have CT performed.⁴⁰
Canaliculitis: 20-MHz ultrasound can be used to detect sulfur granules within the canaliculi.41

Procedures

Periorbital cellulitis: If infection with H influenzae type b or Streptococcus pneumonia is suspected or if systemic involvement is present, a lumbar puncture is indicated to exclude meningeal infection.
Blepharitis: Biopsy may be indicated in some cases to rule out malignancy.
Dacryoadenitis: Lacrimal gland biopsy may be indicated in chronic disease.
Schirmer test is used to assess tear production. It is nonspecific as to the etiology of dry eyes.
Jones dye test is used to assess patency of the lacrimal drainage system. In the first part of the test, a drop of fluorescein is placed in the conjunctival cul-de-sac. After 5 minutes, the nose is examined for the presence of dye. If no dye is present, an obstruction is present and the second part of the test is performed. A cannula is placed into the lacrimal sac, which is then washed with saline. If no fluorescein is noted, the dye is obstructed in the upper (canalicular) portion of the system. If dye is present, then the obstruction is in the lower (sac, duct) portion.⁴²

Treatment

Emergency Department Care

Periorbital cellulitis
- In adult patients who are nontoxic and can be assured of appropriate follow-up, treatment can be with oral antibiotics on an outpatient basis.
- Most pediatric patients require admission. Intravenous antibiotics should be started. Once clinical improvement is noted, the patient should be switched to oral antibiotics.
- Patients who undergo outpatient treatment should be seen daily to ensure clinical improvement.
- Nasal decongestants may be used for the short term to reduce mucosal edema.⁴⁰
- A Clinical Severity Index has been established for periorbital cellulitis in children. It uses systemic features of interaction and fever and local features of location, erythema, extent, and pain and tenderness.⁴³
Blepharitis
- The treatment of blepharitis, regardless of etiology, begins with eyelid hygiene. The patient should be instructed to wash the lids with a nonirritating baby shampoo or a commercially prepared lid scrubbing solution and to use warm compresses for 15 minutes at a time, 3 or 4 times a day.
- For blepharitis suspected to be infectious in nature, a topical antibiotic, such as bacitracin or erythromycin, should be prescribed. The frequency and duration of treatment should be determined based on the severity of the disease process.⁴⁴ Usually, it is applied 2-4 times a day for 2 weeks.
- Posterior blepharitis may be treated with an oral tetracycline, which decreases lipase production in staphylococci preventing plugging of Meibomian glands. This therapy is limited to patients older than8 years due to the risk of tooth enamel discoloration.⁴⁴ Alternative treatment with the macrolide, erythromycin, is safe for use in children younger than 8 years.⁴⁵
- Topical cyclosporine has shown benefit in treatment of posterior blepharitis in a small study of 30 patients compared to treatment with tobramycin/dexamethasone.
- A brief course of preservative-free topical steroids has been shown to decrease ocular surface inflammation.
- If blepharitis is caused by Demodex infestation, treatment with weekly lid scrubs with 50% tea tree oil and daily scrubs with tea tree shampoo for a minimum of 6 weeks has been shown to decrease mite load and improve inflammatory responses.
- Phthiriasis palpebrarum is treated with twice-daily application of petrolatum for 7-10 days. Alternatively, removal of the nits and lice can be accomplished with forceps.
Dacryoadenitis
- Treatment of acute dacryoadenitis is largely supportive as the disease is usually self-limiting. Use warm compresses and nonsteroidal anti-inflammatory drugs.
- If the etiology is bacterial, antibiotic treatment with a first-generation cephalosporin should be started.
- If the etiology is EBV, steroids have been shown to improve the clinical course.
- For chronic dacryoadenitis, treat the underlying condition.
Dacryocystitis
- Treat with oral antibiotics such as amoxicillin-clavulanic acid or dicloxacillin.
- In pediatric patients, the obstruction usually resolves by age 9-12 months. Many pediatric ophthalmologists will wait until after this age to probe the ducts to free the obstruction.
- Dacryocystorhinostomy is the surgical procedure of choice. This procedure allows for the bypassing of the lacrimal duct apparatus as long as the canalicular apparatus is intact.
- Punctal dilation and nasolacrimal irrigation is contraindicated in the acute stage due to the increased risk of periorbital cellulitis.
Canaliculitis
- Remove concretions with gentle pressure using a cotton swab.
- Warm compresses
- Irrigation with penicillin solution to be performed by an ophthalmologist
- Systemic antibiotics, usually penicillin or amoxicillin for 1-2 weeks
- Topical antibiotics - Bacitracin or erythromycin: This rarely achieves complete resolution due to inability of antibiotics to penetrate concretions.
- Canaliculotomy with curettage is the definitive treatment.

Consultations

Consider consultation with an ophthalmologist for any patient who may have orbital involvement.
Most cases of lacrimal system infections can be managed conservatively. Consultation with an ophthalmologist is indicated if the condition is not resolved within 24-48 hours.

Medication

The goals of pharmacotherapy are to eradicate the infection, prevent complications, and reduce morbidity.

Antibiotics, systemic

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Cephalexin (Keflex)

First-generation cephalosporin that inhibits bacterial replication by inhibiting bacterial cell wall synthesis. Bactericidal and effective against rapidly growing organisms forming cell walls.
Resistance occurs by alteration of penicillin-binding proteins. Effective for treatment of infections caused by streptococci or staphylococci, including penicillinase-producing staphylococci. May use to initiate therapy when streptococcal or staphylococcal infection is suspected.
Used orally when outpatient management is indicated.
Has a half-life of 50-80 min. Only 10% is protein bound and greater than 90% recovered unchanged in urine.

Dosing

Adult

250 mg PO qid or 500 mg PO bid for 7-10 d

Pediatric

20 mg/kg/d PO divided q8h for 7-10 d; in more serious infections, may increase dose to 40 mg/kg/d; not to exceed 1 g/d

Interactions

Coadministration with aminoglycosides increases nephrotoxic potential

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections, and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy

Ampicillin and sulbactam (Unasyn)

Drug combination of beta-lactamase inhibitor with ampicillin. Interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms.

Provides useful coverage for most organisms associated with dacryocystitis.

Dosing

Adult

1.5 g (1 g ampicillin + 0.5 g sulbactam) to 3 g (2 g ampicillin + 1 g sulbactam) IV/IM q6-8h; not to exceed 4 g/d sulbactam or 8 g/d ampicillin; dosage reduced with renal failure

Pediatric

<3 months: Not established
3 months to 12 years: 100-200 mg ampicillin/kg/d (150-300 mg Unasyn) IV divided q6h
>12 years: Administer as in adults; not to exceed 4 g/d sulbactam or 8 g/d ampicillin

Interactions

Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction

Clindamycin (Cleocin)

Semisynthetic antibiotic produced by 7(S)-chloro-substitution of 7(R)-hydroxyl group of parent compound lincomycin. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Widely distributes in the body without penetration of CNS. Protein bound and excreted by the liver and kidneys.
Used for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). As an alternative to sulfonamides, clindamycin may be beneficial when used with pyrimethamine in acute treatment of CNS toxoplasmosis in patients with AIDS.

Dosing

Adult

600 mg PO/IV q6-8h

Pediatric

20 mg/kg/d PO/IV divided q6-8h

Interactions

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin

Contraindications

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile

Sulfamethoxazole and trimethoprim (Bactrim DS, Septra DS)

Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.

Antibacterial activity of TMP-SMZ includes common urinary tract pathogens, except Pseudomonas aeruginosa.

Dosing

Adult

160 mg TMP/800 mg SMZ PO q12h for 10-14 d

Pediatric

<2 months: Do not administer
>2 months: 10-20 mg TMP/kg/d PO/IV divided tid/qid for 14 d

Interactions

May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly persons; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine

Contraindications

Documented hypersensitivity; megaloblastic anemia due to folate deficiency; age <2 mo

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Do not use during last trimester of pregnancy due to potential toxicity to newborn (eg, jaundice, hemolytic anemia, kernicterus)
Dosage adjustments (adult adjustments)
CrCl (mL/min) 80-50: Recommended IV dose q18h
CrCl 50-10: Recommended IV dose q24h
CrCl <10: Not recommended
HD: 4-5 mg/kg after HD
During peritoneal dialysis: 0.16-0.8 g q48h
Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBCs frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, chronic alcoholics, elderly persons, those receiving anticonvulsant therapy, or those with malabsorption syndrome); hemolysis may occur in G-6-PD deficient individuals; patients with AIDS may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation

Doxycycline (Bio-Tab, Doryx, Doxy, Periostat, Vibramycin, Vibra-Tabs)

Broad-spectrum, synthetically derived bacteriostatic antibiotic in the tetracycline class. Almost completely absorbed, concentrates in bile, and is excreted in urine and feces as a biologically active metabolite in high concentrations.
Inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. May block dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.

Dosing

Adult

100-200 mg PO qd; some sources recommend using one half of initial dose during second month

Pediatric

Not established

Interactions

Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy

Contraindications

Documented hypersensitivity; severe hepatic dysfunction

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines

Vancomycin (Lyphocin, Vancocin, Vancoled)

Potent antibiotic directed against gram-positive organisms and active against Enterococcus species. Useful in the treatment of septicemia and skin structure infections. Indicated for patients who cannot receive, or have failed to respond to penicillins and cephalosporins or have infections with resistant staphylococci. For abdominal penetrating injuries, it is combined with an agent active against enteric flora and/or anaerobes.
To avoid toxicity, current recommendation is to assay vancomycin trough levels after third dose drawn 0.5 h prior to next dosing. Use creatinine clearance to adjust dose in patients diagnosed with renal impairment.
Used in conjunction with gentamicin for prophylaxis in penicillin-allergic patients undergoing gastrointestinal or genitourinary procedures.

Dosing

Adult

500 mg to 2 g/d IV divided tid/qid 7-10 d
1 mg/0.1 mL for intravitreal injection
25 mg/0.5 mL for subconjunctival injection, or
25 mg/mL 1 gtt q5min for 1-7 doses depending on severity, repeat q1h

Pediatric

Administer as in adults

Interactions

Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in renal failure, neutropenia; red man syndrome is caused by too rapid IV infusion (dose given over a few min) but rarely happens when dose given IV over 2 h administration or as PO or IP administration; red man syndrome is not an allergic reaction

Cefuroxime (Ceftin)

Second-generation cephalosporin maintains gram-positive activity that first-generation cephalosporins have and adds activity against Proteus mirabilis, H influenzae, E coli, Klebsiella pneumoniae, and Moraxella catarrhalis.
Condition of patient, severity of infection, and susceptibility of microorganism determine proper dose and route of administration.

Dosing

Adult

750-1500 mg IV q8h
Adjust dose based on creatinine clearance in renally impaired patients:
CrCl >20: No change
CrCl 10-20: 750 mg q12
CrCl <10: 750 mg q24h
Drug is dialyzable; administer dose after dialysis
Switch to PO dosage form as clinical situation warrants
250-500 mg PO bid

Pediatric

25-50 mg/kg IV q8h; switch to PO dosage form as clinical situation warrants
Oral susp not bioequivalent to tab form
Oral susp: 30 mg/kg/d PO divided bid; not to exceed 1000 mg/d
Tab: 125-250 mg PO q12h

Interactions

Disulfiramlike reactions may occur when alcohol is consumed within 72 h of ingestion; may increase hypoprothrombinemic effects of anticoagulants; may increase nephrotoxicity in patient receiving potent diuretics such as loop diuretics; coadministration with aminoglycosides increase nephrotoxic potential

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Bioavailability increases when taken after food; fungal and microorganism overgrowth may occur with prolonged therapy; dosage adjustment for geriatric patients is not necessary; methicillin-resistant staphylococci are resistant to cefuroxime; use with caution in patients with a history of colitis; oral susp contains phenylalanine (do not give in patients with phenylketonuria)

Nafcillin (Nallpen, Unipen)

Initial therapy for suspected penicillin G-resistant streptococcal or staphylococcal infections.
Use parenteral therapy initially in severe infections. Change to PO therapy as condition warrants.
Because of thrombophlebitis, particularly in the elderly persons, administer parenterally only for short term (1-2 d); change to PO route as clinically indicated.

Dosing

Adult

500-2000 mg IV q4-6h; switch to PO dosage form as clinical situation warrants
250-500 mg PO q4-6h, up to 1 g q4-6h for severe infections

Pediatric

Not approved for pediatric use; off-label dosing administered as follows:
100 mg/kg/d IV divided q6h
Severe infections: May increase to 200 mg/kg/d IV divided q6h; not to exceed 6-12 g/d; switch to PO dosage form as clinical situation warrants
50-100 mg/kg/d PO divided q6h

Interactions

Associated with warfarin resistance when administered concurrently; effects may decrease with bacteriostatic action of tetracycline derivatives

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

To optimize therapy, determine causative organisms and susceptibility; decrease dose in hepatic dysfunction

Amoxicillin and clavulanic acid (Augmentin)

Treats bacteria resistant to beta-lactam antibiotics. For children >3 mo, base dosing protocol on amoxicillin content. Because of different amoxicillin/clavulanic acid ratios in 250-mg tab (250/125) vs 250-mg chewable tab (250/62.5), do not use 250-mg tab until child weighs more than 40 kg.

Dosing

Adult

500-875 mg PO bid

Pediatric

In neonates and infants <3 months: 30 mg/kg/d divided PO q12h
In infants >3 months: 45 mg/kg/d PO divided q12h or 40 mg/kg/d divided q8h
Children >40 kg: Administer as in adults

Interactions

Coadministration with warfarin or heparin increases risk of bleeding

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Administer for minimum of 10 d to eliminate organism; some formulations of Augmentin contain phenylalanine (do not give to phenylketonurics); caution in breastfeeding mothers

Cefaclor (Ceclor)

Second-generation cephalosporin indicated for infections caused by susceptible gram-positive cocci and gram-negative rods.
Determine proper dosage and route based on condition of patient, severity of infection, and susceptibility of causative organism.

Dosing

Adult

750-1500 mg/d PO divided bid/tid

Pediatric

<1 month: Not established
>1 month: 20-40 mg/kg/d PO divided q8-12h; not to exceed 1 g/d

Interactions

Alcoholic beverages consumed <72 h after ingestion may produce disulfiramlike reactions; may increase hypoprothrombinemic effects of anticoagulants; coadministration with potent diuretics and aminoglycosides (eg, loop diuretics) may increase nephrotoxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Risk of toxic reactions may be greater in patients with impaired renal function; administer half dose if CrCl is 10-30 mL/min and one-quarter dose if <10 mL/min; fungal and microorganism overgrowth may occur with prolonged therapy

Tetracycline (Sumycin)

Treats gram-positive and gram-negative organisms as well as mycoplasmal, chlamydial, and rickettsial infections. Inhibits bacterial protein synthesis by binding with 30S and, possibly, 50S ribosomal subunit(s).

Dosing

Adult

250 mg PO q6h; alternatively, 500 mg PO q12h

Pediatric

<8 years: Not recommended
>8 years: 25-50 mg/kg/d PO divided q6h; not to exceed 3 g/d

Interactions

Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of PO contraceptives, causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants

Contraindications

Documented hypersensitivity; severe hepatic dysfunction

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; use during tooth development (last one half of pregnancy through age 8 y) can cause permanent tooth discoloration; Fanconilike syndrome may occur with outdated tetracyclines

Bacitracin (AK-Tracin)

Prevents transfer of mucopeptides into growing cell wall, inhibiting bacterial growth.

Dosing

Adult

Apply 0.25- to 0.5-inch ribbon q3-4h for 7-10 d into conjunctival sac(s)

Pediatric

Apply as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity; vaccinia, varicella, epithelial herpes simplex keratitis, mycobacterial infections, fungal diseases of the eye; patients using steroid combinations after uncomplicated removal of a corneal foreign body

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Ophthalmic ointments may delay healing of corneal epithelia; in deep-seated infections of the eye, supplement with systemic medications; prolonged use may result in overgrowth of nonsusceptible organisms

Erythromycin (E-Mycin)

Macrolide antibiotic that binds to 50S ribosomal subunit blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Does not affect nucleic acid synthesis.
Indicated for infections caused by susceptible strains of microorganisms and for prevention of corneal and conjunctival infections.

Dosing

Adult

Apply 0.5-inch (1.25 cm) ribbon 2-8 times/d depending on severity of infection

Pediatric

Apply as in adults

Interactions

Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis; decreases metabolism of repaglinide, thus increasing serum levels and effects

Contraindications

Documented hypersensitivity; hepatic impairment

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI side effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur

Follow-up

Further Inpatient Care

Further inpatient care is indicated for the treatment of periorbital cellulitis in the pediatric population for the administration of intravenous antibiotics.
Further inpatient care is indicated in any patient who is septic or has orbital involvement.

Complications

Periorbital cellulitis
- Toxic shock syndrome
- Eschar formation leading to scarring
- Meningitis
- Orbital cellulitis
- Necrotizing fasciitis has been described in a case of periorbital cellulitis in an immunocompromised patient
Blepharitis
- Hordeolum
- Chalazion
- Scarring of the cornea, which could lead to blindness
- Trichiasis (misdirection of eyelashes)
- Corneal infection
Dacryocystitis
- Dacryocystitis may be associated with periorbital cellulitis. Rarely, it may be associated with orbital cellulitis or abscess formation. This is usually prevented by the orbital septum, which surrounds the lacrimal sac.
- Complications may occur during a dacryocystorhinostomy, including hemorrhage, infection, and CSF leakage.
Canaliculitis - Epiphora

Prognosis

Periorbital cellulitis - With appropriate antibiotics, the prognosis is good.
Blepharitis - Typically, this is a chronic disease with waxing and waning of symptoms.
Dacryoadenitis
- Prognosis of the acute form is excellent as it is a self-limiting process.
- Prognosis of the chronic form depends on the underlying disease process.
Dacryocystitis - Success rates for dacryocystorhinostomy are good. External procedures fare better due to the ability to create a larger ostium.
Canaliculitis - Prognosis is excellent with definitive treatment by canaliculotomy with curettage.

Patient Education

Periorbital cellulitis - For excellent patient education resources see eMedicine's patient education article, Cellulitis.
Blepharitis
- Blepharitis Fact Sheet is available for purchase from the American Academy of Ophthalmology.
- The use of eye makeup, especially eyeliner, can cause acute exacerbations by plugging the glands.

Miscellaneous

Medicolegal Pitfalls

Failure to recognize orbital involvement

References

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Keywords

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

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

Further Reading

eMedicine Specialties > Emergency Medicine > Ophthalmology

Periorbital Infections

Introduction

Background

Pathophysiology

Sex

Age

Clinical

History

Physical

Causes

Differential Diagnoses

Other Problems to Be Considered

Workup

Laboratory Studies

Imaging Studies

Procedures

Treatment

Emergency Department Care

Consultations

Medication

Antibiotics, systemic

Cephalexin (Keflex)

Dosing

Adult

Pediatric

Interactions

Contraindications

Precautions

Pregnancy

Precautions

Ampicillin and sulbactam (Unasyn)

Dosing

Adult

Pediatric

Interactions

Contraindications

Precautions

Pregnancy

Precautions

Clindamycin (Cleocin)

Dosing

Adult

Pediatric

Interactions

Contraindications

Precautions

Pregnancy

Precautions

Sulfamethoxazole and trimethoprim (Bactrim DS, Septra DS)

Dosing

Adult

Pediatric

Interactions

Contraindications

Precautions

Pregnancy

Precautions

Doxycycline (Bio-Tab, Doryx, Doxy, Periostat, Vibramycin, Vibra-Tabs)

Dosing

Adult

Pediatric

Interactions

Contraindications

Precautions

Pregnancy

Precautions

Vancomycin (Lyphocin, Vancocin, Vancoled)

Dosing

Adult

Pediatric

Interactions

Contraindications

Precautions

Pregnancy

Precautions

Cefuroxime (Ceftin)

Dosing

Adult

Pediatric