Periorbital Infections 

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

Overview

Background

Periorbital infections consist of a group of infections that can be broadly classified into 2 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. (See Presentation and Workup.)

Periorbital cellulitis

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. Periorbital cellulitis is predominantly, although not exclusively, a pediatric disease (see the image below). (See Presentation, Workup, Treatment, and Medication.)[1, 2]

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.

Periorbital cellulitis represents the first of the 5 nonprogressive types of orbital infections. These are classified as follows[3] :

  • Group 1 - Preseptal cellulitis

  • Group 2 - Orbital cellulitis

  • Group 3 - Subperiosteal abscess

  • Group 4 - Orbital abscess

  • Group 5 - Cavernous sinus thrombosis

Lacrimal system infections

Infections of the lacrimal system are classified based on the location of the infection; they include the following (see Presentation, Workup, Treatment, and Medication):

  • Blepharitis - 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; blepharitis primarily affects older persons (mean age 40-50 years)[4]

  • Canaliculitis – Inflammation of the canaliculi

  • Dacryoadenitis - Inflammation of the lacrimal gland

  • Dacryocystitis - Inflammation of the lacrimal duct or sac; obstructed lacrimal ducts causing dacryocystitis are common in infants and usually resolve by age 9-12 months (see the image below)[5]

    Acute dacryocystitis. Acute dacryocystitis.

Patient education

For patient education information, see Cellulitis. A blepharitis fact sheet is available for purchase from the American Academy of Ophthalmology.[6]

Anatomy

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.[7] The orbital septum acts as a physical barrier to the spread of infection.

Note the anatomical drawings below.

Upper eyelid anatomy. Upper eyelid anatomy.
Lower eyelid anatomy. Lower eyelid anatomy.

Lacrimal system

The lacrimal system includes the structures involved in the 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 the lateral edge to the medial edge, pushing the tear film across the surface of the eye. Most of the tear volume is lost through 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.[7]

Note the anatomical drawings below.

Eye and lacrimal duct, anterior view. Eye and lacrimal duct, anterior view.

Etiology

Periorbital cellulitis

Periorbital cellulitis can occur by several mechanisms, including the following[2, 8] :

  • Infection as a result of local trauma, including insect bites

  • Infection as a result of spread from contiguous structures, as in conjunctivitis, hordeolum, lacrimal system infections, and impetigo

  • Infections secondary to hematogenous spread during bacteremia due to nasopharyngeal pathogens

  • Infection secondary to sinusitis, causing venous and lymphatic congestion - Sinusitis may be of odontogenic origin[9] ; thorough examination of dentition may be warranted

Infectious organisms

When associated with trauma, periorbital cellulitis can be caused by the following bacterial species:

  • Staphylococcus aureus - This may include methicillin-resistant S aureus[10] ; treatment should be tailored to local incidence of infection

  • Streptococcus pyogenes (group A streptococci)

In the absence of trauma, periorbital cellulitis can be caused by the following microbes:

  • Streptococcus pneumoniae

  • Haemophilus influenzae type b - Was the predominant cause of periorbital cellulitis prior to the advent of the Hib vaccine but has now been shown to cause only rare cases[1, 11, 12, 13]

Other unusual causes of periorbital cellulitis include the following:

  • Neisseria gonorrhoeae[14]

  • Neisseria meningitidis[15, 16]

  • Vaccinia virus[17] - Has been reported in a laboratory worker; autoinoculation resulting in periorbital infection in patients receiving the vaccine has been reported[18]

  • Herpes simplex virus

  • Mycobacterium tuberculosis[19]

  • Bacillus anthracis[20]

  • Taenia solium – Periorbital cellulitis can develop secondary to orbital cysticercosis caused by this organism[21]

Blepharitis

Anterior blepharitis is usually secondary to infection or seborrheic in nature, or else it is a combination of both. If the pilosebaceous glands of Zeiss and Moll become infected, an abscess may occur. This abscess is known as an external hordeolum, or stye.[22] Cell-mediated immunologic mechanisms have been implicated in the development of chronic blepharitis.[23, 24]

Posterior blepharitis is caused by Meibomian gland dysfunction. The Meibomian gland secretes the oily layer of the tear film. This oily layer is responsible for preventing excessive evaporation of the aqueous 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.[25]

The use of eye makeup, especially eyeliner, can cause acute exacerbations of blepharitis by plugging the glands.[26]

Anterior blepharitis

Causative organisms in anterior blepharitis include the following:

  • Infectious etiology usually due to Staphylococcus species[22]

  • Other bacteria include Propionibacterium acnes,Moraxella species, and Corynebacterium species[5, 27]

  • Helicobacter pylori - Associated with blepharitis, but cause and effect have not been established[28]

  • Viruses - Herpes simplex virus, herpes zoster virus, and human papillomavirus

  • Mites -Demodex folliculorum and Demodex brevis[29]

  • Lice -Phthirus pubis, which causes a condition known as phthiriasis palpebrarum[30]

  • Noninfectious entities such as ocular rosacea and seborrheic dermatitis also cause anterior blepharitis

Posterior blepharitis

Etiologic characteristics of posterior blepharitis include the following:

  • Meibomian gland dysfunction leading to increased evaporation of the protective tear layer[31]

  • Most frequently associated with rosacea

  • Pityrosporum fungal infection is associated with Meibomian gland dysfunction[32]

Dacryoadenitis

Dacryoadenitis is caused by local infection of the lacrimal gland by bacteria or viruses. Chronic dacryoadenitis associated with inflammation and swelling of the salivary glands of unknown origin is called Mikulicz disease. When associated with other entities such as tuberculosis, sarcoidosis, or lymphoma, it is termed Mikulicz syndrome. This was previously considered a subtype of Sjögren syndrome, although now differences between the 2 entities have been determined.[33]

Bacteria

Dacryoadenitis is most often caused by gram-positive cocci, usually staphylococci. It may also be caused by S pneumoniae.

Viruses

Prior to increased immunization rates, the mumps virus was most often implicated in the development of dacryoadenitis. Now, the Epstein-Barr virus is most often associated with chronic dacryoadenitis.[34]

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 or secondary to infection, tumor, or trauma.[7]

Infectious causes include gram-positive isolates (Staphylococcus and Streptococcus species), in 71-78% of cases, and gram-negative isolates, in 22-29% of cases.[35, 36] Rarely, dacryocystitis may result from mucormycosis.[37]

Canaliculitis

Canaliculitis is caused by infection of the canaliculi; often, it is chronic. The disorder may also be iatrogenic, occurring after the use of instrumentation or the placement of silicone plugs in the treatment of dry eyes.[38]

It is classically taught that the most common pathogens of canaliculitis are Actinomyces israelii and Nocardia (formerly known as Streptothrix) species.[5, 39]

Case reviews, however, have shown mixed flora associated with infection. Species isolated include Staphylococcus species, Escherichia coli, Haemophilus species, Pseudomonas aeruginosa, Klebsiella oxytocia,[40] Arcanobacterium (previously Corynebacterium) haemolyticum,[41] and M chelonae.[42]

Prognosis

Prognoses in periorbital infections are as follows:

  • 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.

Complications

Periorbital cellulitis

Complications of periorbital cellulitis include the following:

  • Recurrent periorbital cellulitis (RPOC) - Three periorbital infections occurring within 1 year, spaced by at least 1 month of convalescence[43]

  • Toxic shock syndrome

  • Eschar formation leading to scarring

  • Meningitis

  • Orbital cellulitis

  • Intracranial extension of infection

  • Periorbital necrotizing fasciitis - A potential complication with devastating results; the mortality rate is reported to be 14.4%[44]

Blepharitis

Complications of blepharitis include the following:

  • Hordeolum

  • Chalazion

  • Scarring of the cornea, which could lead to blindness

  • Trichiasis (misdirection of eyelashes)

  • Corneal infection

  • Endophthalmitis - Patients with blepharitis undergoing intraocular surgery may have an increased risk of developing this condition

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.[45]

Complications may occur during a dacryocystorhinostomy, including hemorrhage, infection, and cerebrospinal fluid (CSF) leakage.

Canaliculitis

Epiphora may result from failure of tear film to appropriately drain through the lacrimal system.

Pathophysiology

S aureus, Staphylococcus epidermidis, and S pyogenes account for approximately 75% of pediatrics periorbital infections. Staphylococcus and Streptococcus are the most two common pathogens responsible for pediatric orbital cellulitis.[46]

Epidemiology

Periorbital cellulitis is primarily a pediatric disease, occurring mostly in children younger than 5 years. Periorbital cellulitis is almost three times more common than orbital cellulitis.

While orbital cellulitis is more common in the pediatric population, it can affect all age groups. In one retrospective analysis, the average age of affected patients was 6.8 years (ranging from age 1 week to 16 years).[47] Worldwide, orbital cellulitis occurs more often in winter. It is associated with upper respiratory tract infections, and most cases have a unilateral presentation.[48, 49]

Periorbital cellulitis has no sexual predilection. Orbital infections have a male-to-female ratio of 2:1. 

 

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

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

 

DDx

Diagnostic Considerations

Conditions to consider in the differential diagnosis of periorbital cellulitis include the following:

  • Angioedema

  • Insect bites

  • Cavernous sinus thrombosis

  • Chalazion

  • Internal and external hordeola

  • Idiopathic orbital inflammation (orbital pseudotumor)[55]

  • Mucormycosis

  • Nephrotic syndrome

  • Orbital cellulitis

  • Pott's puffy tumor[56, 57]

  • Periorbital necrotizing fasciitis

Conditions to consider in the differential diagnosis of blepharitis include the following[58] :

  • Basal cell carcinoma

  • Squamous cell carcinoma

  • Sebaceous cell carcinoma

  • Actinic keratosis

  • Keratoacanthoma

Conditions to consider in the differential diagnosis of dacryoadenitis include the following:

  • Sjögren syndrome

  • Sarcoidosis

  • Tumors - Cause about 25% of lacrimal gland enlargement[59]

Conditions to consider in the differential diagnosis of canaliculitis include the following:

  • Carcinoma[60]

  • Melanoma

Differential Diagnoses

 

Workup

Approach Considerations

Laboratory studies

The following laboratory studies may be performed in patients with periorbital infection:

  • Periorbital cellulitis - Diagnosis is based primarily on clinical findings. Laboratory or radiologic workup is not required. Thus, a complete blood cell (CBC) count with differential is not routinely necessary, but it may be helpful if bacteremia or sepsis is a concern; blood cultures may also be performed if bacteremia or sepsis is a concern; skin culture has a very low yield. Wound culture of a purulent drainage site may be helpful if a resistant or unusual pathogen is suspected.[43]

  • Dacryoadenitis - A CBC count 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.

  • Canaliculitis and dacryocystitis - Culture of expressed material may help to guide therapy

  • Blepharitis - No laboratory studies are indicated routinely

Lumbar puncture

If a patient with periorbital cellulitis is toxic appearing, a lumbar puncture may be indicated to exclude meningeal infection.

Biopsy

Biopsy may be indicated in the following cases:

  • Blepharitis - Biopsy may be indicated in some cases to rule out malignancy

  • Dacryoadenitis - Lacrimal gland biopsy may be indicated in chronic disease

Schirmer test

The Schirmer test is used to assess tear production. Results are nonspecific as to the etiology of dry eyes.

Imaging Studies

Periorbital cellulitis

Contrast-enhanced computed tomography (CT) scanning of the orbits should be performed if there is concern for orbital and subperiosteal involvement and cavernous sinus thrombosis. CT scanning also helps to distinguish sinusitis as a cause.

Indications for CT scanning include the following[61] :

  • Inability to perform a full evaluation of the eye due to edema

  • Proptosis

  • Ophthalmoplegia

  • Decreased visual acuity or color vision

  • Bilateral periorbital edema

  • Inability to exclude postseptal involvement
  • Central nervous system involvement (eg, focal neurological deficits, seizure, altered mental status)
  • Clinical deterioration or no improvement after 24-48 hours following initiation of appropriate treatment

CT scanning will show lid edema but no proptosis or "streaking" of the orbital fat, which lies posterior to the orbital septum.

Patients whose condition fails to improve after 24-36 hours of appropriate antimicrobial therapy should also have CT performed.[61]

In an attempt to better target patients needing emergent CT scanning, Rudloe et al presented a recursive partitioning model for identification of predictors of intraorbital or intracranial abscess, for use in pediatric patients with signs or symptoms of periorbital infection.[62]

Results of the study confirmed that patients with proptosis and/or pain or limitation of extraocular movements are at high risk for intraorbital abscess, though many patients with abscess do not have these predictors. The investigators also concluded, based on multivariate analysis, that the following findings can identify patients at significant risk when the obvious predictors are not present:

  • Peripheral blood neutrophil count over 10,000/μ L

  • No infectious conjunctivitis,

  • Periorbital edema

  • Age older than 3 years

  • Previous antibiotic use

Magnetic resonance imaging (MRI) with MR venography is the study of choice to rule out cavernous sinus thrombosis, although the initial evaluation is often done with CT venography.[63]

Canaliculitis

20-MHz ultrasonography can be used to detect sulfur granules within the canaliculi.[64]

Jones Dye Test

The 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.

In the second part of the test, 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.[65]

Other Tests

The main role of MRI is the evaluation of intracranial complications such as cerebritis or cavernous sinus thrombosis. 

 

Treatment

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.

Complications

Complications of periorbital cellulitis include the following:

  • Local abscess formation
  • Orbital cellulitis
  • Intracranial extension of infection
 

Medication

Medication Summary

Antibiotics are used in the treatment of periorbital infections, with the specific disorder dictating whether topical, oral, or intravenous agents are administered. As previously stated, for example, treatment of orbital cellulitis commonly starts with intravenous antibiotics in pediatric patients and with oral antibiotics in adults.

Topical antibiotics such as bacitracin, erythromycin, and levofloxacin are used in cases of blepharitis, if the disease is thought to be infectious.

Bacteria frequently associated with periorbital infections include species of Streptococcus and Staphylococcus.

Antibiotics, Other

Class Summary

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

Cephalexin (Keflex)

Cephalexin is a first-generation cephalosporin that inhibits bacterial replication by inhibiting bacterial cell wall synthesis. It is bactericidal and effective against rapidly growing organisms forming cell walls. Resistance occurs through alteration of penicillin-binding proteins.

Cephalexin is effective for the treatment of infections caused by streptococci or staphylococci, including penicillinase-producing staphylococci. It may be used to initiate therapy when streptococcal or staphylococcal infection is suspected. The drug is used orally when outpatient management is indicated.

Cephalexin has a half-life of 50-80 minutes. Only 10% is protein bound and more than 90% is recovered unchanged in urine.

Ampicillin and sulbactam (Unasyn)

This agent features ampicillin combined with a beta-lactamase inhibitor. It interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms. The ampicillin-sulbactam combination provides useful coverage for most organisms associated with dacryocystitis.

Clindamycin (Cleocin)

This agent is a semisynthetic antibiotic produced by 7(S)-chloro-substitution of the 7(R)-hydroxyl group of the parent compound, lincomycin. Clindamycin inhibits bacterial growth, possibly by blocking dissociation of peptidyl transfer ribonucleic acid (tRNA) from ribosomes, causing RNA-dependent protein synthesis to arrest. The drug is widely distributed in the body without penetration of the central nervous system (CNS). It is protein bound and excreted by the liver and kidneys.

Clindamycin is used for the treatment of serious skin and soft tissue staphylococcal infections. It is 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 acquired immunodeficiency syndrome (AIDS).

Trimethoprim/sulfamethoxazole (Bactrim DS, Septra DS)

Trimethoprim/sulfamethoxazole inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. The antibacterial activity of trimethoprim/sulfamethoxazole includes common urinary tract pathogens, except Pseudomonas aeruginosa.

Doxycycline (Doryx, Doxy 100, Periostat, Oraxyl, Vibramycin)

Doxycycline is a broad-spectrum, synthetically derived, bacteriostatic antibiotic in the tetracycline class. It is almost completely absorbed, concentrates in bile, and is excreted in urine and feces as a biologically active metabolite in high concentrations.

Doxycycline inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. It may block the dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.

Vancomycin

Vancomycin is a potent antibiotic directed against gram-positive organisms and active against Enterococcus species. It is useful in the treatment of septicemia and skin structure infections and is indicated for patients who cannot receive, or have failed to respond to, penicillins and cephalosporins or who have infections with resistant staphylococci. For abdominal penetrating injuries, vancomycin is combined with an agent active against enteric flora and/or anaerobes.

To avoid toxicity, the current recommendation is to assay vancomycin trough levels after the third dose, drawn 0.5 hour prior to the next dosing. Use creatinine clearance to adjust the dose in patients diagnosed with renal impairment.

Vancomycin is used in conjunction with gentamicin for prophylaxis in penicillin-allergic patients undergoing gastrointestinal or genitourinary procedures.

Cefuroxime (Ceftin, Zinacef)

Cefuroxime is a second-generation cephalosporin that maintains the gram-positive activity found in first-generation cephalosporins and adds activity against Proteus mirabilis, H influenzae, E coli, K pneumoniae, and M catarrhalis.

The condition of the patient, the severity of infection, and the susceptibility of the microorganism determine the proper dose and route of administration.

Nafcillin

Nafcillin is used in the initial therapy for suspected penicillin G-resistant streptococcal or staphylococcal infections. Parenteral therapy should be used initially in severe infections, with a change made to oral treatment as the condition warrants.

Because of thrombophlebitis, particularly in elderly persons, nafcillin should be administered parenterally only for a short term (1-2 days); change to an oral antibiotic should be made as clinically indicated.

Amoxicillin and clavulanic acid (Augmentin)

This drug combination treats bacteria resistant to beta-lactam antibiotics. For children older than 3 months, base the dosing protocol on amoxicillin content. Because of different amoxicillin/clavulanic acid ratios in the 250 mg tablet (250/125) versus the 250 mg chewable tablet (250/62.5), do not use the 250 mg tablet until the child weighs more than 40 kg.

Cefaclor

Cefaclor is a second-generation cephalosporin indicated for infections caused by susceptible gram-positive cocci and gram-negative rods. Determine the proper dosage and route based on the patient's condition, the infection's severity, and the causative organism's susceptibility.

Tetracycline

Tetracycline treats gram-positive and gram-negative organisms as well as mycoplasmal, chlamydial, and rickettsial infections. It inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunits.

Bacitracin (Baciguent)

This agent prevents the transfer of mucopeptides into the growing cell wall, inhibiting bacterial growth.

Erythromycin ophthalmic (Ilotycin)

This agent is a macrolide antibiotic that binds to the 50S ribosomal subunit, blocking dissociation of peptidyl tRNA from the ribosomes and causing RNA-dependent protein synthesis to arrest. It does not affect nucleic acid synthesis.

Erythromycin ophthalmic is indicated for infections caused by susceptible strains of microorganisms and for the prevention of corneal and conjunctival infections.

 

Questions & Answers

Overview

What are periorbital infections?

What is periorbital cellulitis?

How is periorbital cellulitis classified?

How are periorbital infections of the lacrimal system classified?

What is the anatomy of orbital septum relevant to periorbital infections?

What is the anatomy of lacrimal system relevant to periorbital infections?

What causes canaliculitis?

What causes periorbital cellulitis?

What causes periorbital cellulitis following trauma?

What causes periorbital cellulitis in the absence of trauma?

What are other unusual causes of periorbital cellulitis?

What causes blepharitis?

What causes anterior blepharitis?

What causes posterior blepharitis?

What causes dacryoadenitis?

What causes dacryocystitis?

What is the prognosis of periorbital infections?

What are the possible complications of periorbital cellulitis?

What are the possible complications of blepharitis?

What is the prognosis of dacryocystitis?

What is the prognosis of canaliculitis?

What is the pathophysiology of periorbital infections?

What is the prevalence of periorbital infections?

Presentation

Which clinical history findings are characteristic of periorbital cellulitis?

Which clinical history findings are characteristic of blepharitis?

Which clinical history findings are characteristic of dacryoadenitis?

Which clinical history findings are characteristic of dacryocystitis?

Which clinical history findings are characteristic of canaliculitis?

Which physical findings are characteristic of periorbital cellulitis?

Which physical findings are characteristic of anterior blepharitis?

Which physical findings are characteristic of posterior blepharitis?

Which physical findings are characteristic of dacryoadenitis?

Which physical findings are characteristic of dacryocystitis?

Which physical findings are characteristic of canaliculitis?

DDX

Which conditions should be included in the differential diagnosis of periorbital cellulitis?

Which conditions should be included in the differential diagnosis of blepharitis?

Which conditions should be included in the differential diagnosis of dacryoadenitis?

Which conditions should be included in the differential diagnosis of canaliculitis?

What are the differential diagnoses for Periorbital Infections?

Workup

What is the role of lab testing in the workup of periorbital infections?

What is the role of lumbar puncture in the workup of periorbital infections?

What is the role of biopsy in the diagnosis of periorbital infections?

What is the role of Schirmer test in the diagnosis of periorbital infections?

What is the role of CT scanning in the diagnosis of periorbital infections?

What is the role of MRI in the diagnosis of periorbital infections?

What is the role of ultrasonography in the workup of preorbital infections?

What is the role of Jones dye test in the diagnosis of periorbital infections?

How are intracranial complications of periorbital infections evaluated?

Treatment

How is periorbital cellulitis treated?

How is blepharitis treated?

How is dacryoadenitis treated?

How is dacryocystitis treated?

What are treatments for canaliculitis treated?

Which specialist consultations are beneficial to patients with periorbital infections?

What are the possible complications of periorbital cellulitis?

Medications

Which medications are used in the treatment of periorbital infections?

Which medications in the drug class Antibiotics, Other are used in the treatment of Periorbital Infections?