Periorbital Infections Clinical Presentation

Updated: Jul 31, 2018
  • Author: Bobak Zonnoor , MD; Chief Editor: Gil Z Shlamovitz, MD, FACEP  more...
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Presentation

History

Periorbital cellulitis

Patient history may include the following:

  • An antecedent history of superficial skin break (due to infected insect bite, impetigo, acne, eczema), trauma to the periorbital skin, infection of adjacent structures (eg, hordeolum, dacryocystitis/dacryoadenitis), upper respiratory infection, or sinusitis

  • A sudden increase in temperature and rapid swelling of tissue

  • A history of underlying illness (eg, human immunodeficiency virus [HIV], acute lymphoblastic leukemia), which would increase the patient's risk of infection

Blepharitis

Characteristics include the following:

  • Anterior blepharitis - Erythema, pruritus, and crusting of lid margins; typically without discharge

  • Posterior blepharitis – Epiphora, foreign body or burning sensation, [50] blurred vision, and photophobia

Dacryoadenitis

The disease is characterized by swelling of upper lateral eyelid and scleral injection. If dacryoadenitis is caused by a viral infection, the area is modestly tender. Bacterial causes result in more severe tenderness. [25]

Dacryocystitis

A history of chronic conjunctivitis or recent upper respiratory infection may be present. Other signs include the following:

  • Epiphora

  • Fever

  • Swelling, tenderness, and erythema usually localized at the medial canthal area

  • Purulent discharge

Canaliculitis

Patient history may include the following:

  • Epiphora

  • Irritation or pruritus of medial portion of affected eyelid

Next:

Physical Examination

Periorbital cellulitis

Examination may reveal the following:

  • Unilateral erythema, swelling, warmth, and tenderness of the lids without evidence of orbital congestion (proptosis, decreased extraocular movement, blurry vision, ophthalmoplegia, chemosis), as demonstrated in the image below

    Periorbital cellulitis. This image shows an 8-year Periorbital cellulitis. This image shows an 8-year-old patient who presented with unilateral eyelid swelling and erythema.
  • Fever

  • Vesicles - If associated with herpetic infection

  • Violaceous discoloration of the lid - More commonly associated with H influenzae but may be associated with infection with S pneumoniae. [51]

  • If associated with trauma, there may be a break in the skin overlying the area of cellulitis.

  • The eye itself is not involved, so pupillary reaction and visual acuity are preserved.

Blepharitis

Anterior blepharitis

Signs of anterior blepharitis include the following:

  • Crusting at the base of the lash (known as scurf or collarettes), erythema of lid

  • Usually, no discharge

  • Poliosis, or depigmentation of the lash, may occur [22]

  • If associated with ocular rosacea, telangiectatic vessels may be noted on the lid margins and cheeks [52]

  • In chronic cases, ulceration of the lid, lid notching (tylosis), thinning of eyelashes (madarosis), or misdirection of the eyelashes (trichiasis) may be noted [27]

Posterior blepharitis

Signs of posterior blepharitis include the following:

  • Decreased Schirmer score

  • Conjunctival hyperemia [53]

Dacryoadenitis

The signs of dacryoadenitis include the following:

  • Soft tissue swelling that is greatest at the lateral portion of the upper lid margin [54]

  • Deformation of the upper lid into a characteristic S shape [5]

  • If caused by a viral infection, the area is modestly tender; bacterial causes result in more severe tenderness [25]

  • Decreased Schirmer score

Dacryocystitis

Erythema, swelling, warmth, and tenderness may be noted over the lacrimal sac at the inferior aspect of the medial canthus. Application of pressure to the area overlying the lacrimal sac may cause expression of purulent material from the lacrimal puncta. (See the image below.)

Acute dacryocystitis. Acute dacryocystitis.

Canaliculitis

Signs of canaliculitis include the following:

  • Edematous, "pouting" punctum

  • Erythema of adjacent conjunctiva

  • Mattering of the eyelid

  • Mucous regurgitation from punctum on application of pressure

  • Yellowish concretions may be expressed from the punctum; these are sulfur granules produced by Actinomyces israelii

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