Periorbital Infections Treatment & Management

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

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.[49]
    • 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.[54]
    • Patients with odontogenic origin for infection may have improved outcomes with early definitive treatment of dentition.[55]
  • 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. Collarettes at the base of the lashes can be gently removed using a cotton-tipped applicator.
    • For blepharitis suspected to be infectious in nature, a topical antibiotic, such as bacitracin, erythromycin,[56] or levofloxacin[57] should be prescribed. The frequency and duration of treatment should be determined based on the severity of the disease process.[58] 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 than 8 years due to the risk of tooth enamel discoloration.[58] Alternative treatment with topical azithromycin is effective and safe.[59]
    • Sodium fusidate, containing fusidic acid, is effective against most species responsible for blepharitis including methicillin-resistant Staphylococcus aureus.[14] This medication is not approved for use in the United States but is available in Europe, Canada, Australia, and New Zealand.[60]
    • Topical cyclosporine has shown benefit in treatment of posterior blepharitis in a small study of 30 patients compared to treatment with tobramycin/dexamethasone.[4]
    • Botulinum toxin A injection has been shown to be beneficial in the treatment of chalazia.[61]
    • A brief course of preservative-free topical steroids has been shown to decrease ocular surface inflammation. Its use is reserved for cases with severe inflammation.
    • If blepharitis is caused by infestation with the mite Demodex folliculorum, 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.[62]
    • Phthiriasis palpebrarum has been treated with twice-daily application of petrolatum for 7-10 days. This therapy fails to kill ova, and infection may be persistent. An alternative therapy has been proposed using pilocarpine 4% gel twice daily for 10 days. The mechanism of action of this therapy is not well understood.[63] In addition, 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.[64]
    • 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.[65]
    • 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.[66]
    • 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.
Next

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.
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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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