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Periorbital Infections Treatment & Management

  • Author: Bobak Zonnoor , MD; Chief Editor: Robert E O'Connor, MD, MPH  more...
 
Updated: Dec 02, 2015
 

Approach Considerations

Periorbital cellulitis

In adult patients who are nontoxic and can be assured of appropriate follow-up, treatment can be administered with oral antibiotics on an outpatient basis. No evidence suggests that intravenous antibiotics are superior to oral antibiotics in the management of simple periorbital cellulitis in terms of faster recovery or prevention of complications.[66] The antibiotic should offer coverage of Staphylococcus and Streptococcus.[43]

Patients who undergo outpatient treatment should be seen daily to ensure clinical improvement. The length of antibiotic treatment is 7-10 days; however, it should be guided by symptom resolution. Clinical improvement should be evident within 1-2 days after initiation of antibiotics.[67] Nasal decongestants may be used for the short term to reduce mucosal edema.[61]

Inpatient care, with administration of intravenous antibiotics, is indicated for the treatment of periorbital cellulitis in most pediatric patients. Full septic evaluation must be considered if the patient is toxic-appearing or has any signs of nervous system involvement (eg, headache, vomiting, seizure, cranial nerve deficits).[43] Once clinical improvement is noted, the patient should be switched to oral antibiotics. 

A Clinical Severity Index has been established for periorbital cellulitis in children. It uses systemic features of patient interaction and fever, as well as local features of location, erythema, extent of eye opening, and pain and tenderness.[68]

Patients with an infection of odontogenic origin may have improved outcomes with early definitive treatment of dentition.[69]

Assessment considerations

A study by Upile and colleagues indicated that in most cases, daily assessment of hospital patients with periorbital cellulitis only infrequently requires an otorhinolaryngologist, despite concerns regarding possible intracranial and orbital complications in these patients. Using a retrospective analysis of 213 case notes from a tertiary children’s hospital, the investigators found that most patients were successfully managed by pediatricians and ophthalmologists.

Upile et al concluded that in patients with periorbital cellulitis, otorhinolaryngologic assessment is required only after first-line treatment of the disease has failed.[70]

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.

If the blepharitis is suspected of being infectious, a topical antibiotic such as bacitracin, erythromycin,[71] or levofloxacin[72] should be prescribed. The frequency and duration of treatment should be determined based on the severity of the disease process.[73] Usually, the topical antibiotic is applied 2-4 times daily for 2 weeks.[74]

Posterior blepharitis may be treated with an oral tetracycline; this medication decreases lipase production in staphylococci, preventing plugging of Meibomian glands. Such therapy is limited to patients older than 8 years due to the risk of tooth enamel discoloration.[73] Alternative treatment with topical azithromycin is effective and safe.[75]

Other medications used to treat blepharitis include the following[76] :

  • Sodium fusidate - This agent, containing fusidic acid, is effective against most microbial species responsible for blepharitis, including methicillin-resistant S aureus [27, 77]
  • Topical cyclosporine - This showed benefit in the treatment of posterior blepharitis in a small study of 30 patients, compared with treatment with tobramycin/dexamethasone [23]
  • Botulinum toxin A injection - Such therapy has been shown to be beneficial in the treatment of chalazia [78]
  • Steroids - 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 D 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.[79]

Phthiriasis palpebrarum has been treated with twice-daily application of petrolatum for 7-10 days. This therapy fails to kill ova, however, 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.[80] In addition, removal of the nits and lice can be accomplished with forceps.

Dacryoadenitis

Treatment of acute dacryoadenitis is largely supportive because the disease is usually self-limiting. Use warm compresses and nonsteroidal anti-inflammatory drugs (NSAIDs).

If the etiology is bacterial, antibiotic treatment with a first-generation cephalosporin should be started. If the disease has been caused by Epstein-Barr virus, steroids have been shown to improve the clinical course.[81] For chronic dacryoadenitis, treat the underlying condition.

Dacryocystitis

Treat this disorder 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.[82]

Dacryocystorhinostomy is the surgical procedure of choice. This operation allows for the bypassing of the lacrimal duct apparatus as long as the canalicular apparatus is intact.[83]

Punctal dilation and nasolacrimal irrigation is contraindicated in the acute stage due to the increased risk of periorbital cellulitis.

Canaliculitis

Treatments for this disorder include the following:

  • Concretion removal 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 the inability of antibiotics to penetrate concretions
  • Canaliculotomy with curettage - Considered the definitive treatment

Consultations

Consider consultation with an ophthalmologist, otolaryngologist, or neurosurgeon for any patient who may have orbital involvement.

Most cases of lacrimal system infection can be managed conservatively. Consultation with an ophthalmologist or otolaryngologist is indicated if the condition is not resolved within 24-48 hours.

Next

Complications

Complications of periorbital cellulitis include the following:

  • Local abscess formation
  • Orbital cellulitis
  • Intracranial extension of infection
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Contributor Information and Disclosures
Author

Bobak Zonnoor , MD Resident Physician, Department of Emergency Medicine, SUNY Downstate Medical Center, Kings County Hospital

Bobak Zonnoor , MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

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.

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

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians, 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.

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 Association for Physician Leadership, American Heart Association, Medical Society of Delaware, Society for Academic Emergency Medicine, Wilderness Medical Society, American Medical Association, National Association of EMS Physicians

Disclosure: Nothing to disclose.

Additional Contributors

R Gentry Wilkerson, MD, FACEP, FAAEM Assistant Professor, Coordinator for Research, Department of Emergency Medicine, University of Maryland School of Medicine

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

Disclosure: Nothing to disclose.

Acknowledgements

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

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Periorbital cellulitis. This image shows an 8-year-old patient who presented with unilateral eyelid swelling and erythema.
Acute dacryocystitis.
Upper eyelid anatomy.
Lower eyelid anatomy.
Eye and lacrimal duct, anterior view.
 
 
 
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