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]
The recommendation is to use combination regiments for empiric treatment of periorbital cellulitis:
-One of the following agents: Clindamycin OR Trimethoprim-Sulfamethoxazole (TMP-SMX)
-PLUS one of the following agents: Amoxicillin, Amoxicillin-Clavulanic acid, Cephalexin, Cefpodoxime or Cefdinir
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 if worsening symptoms or no response to outpatient treatment over 24-48 hours, and 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] CT scan is recommended for those who are not responding to treatment to evaluate for orbital cellulitis, abscess or any potential complications. 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] :
-
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]
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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:
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Concretion removal with gentle pressure using a cotton swab
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Warm compresses
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Irrigation with penicillin solution - To be performed by an ophthalmologist
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Systemic antibiotics - Usually penicillin or amoxicillin for 1-2 weeks
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Topical antibiotics - Bacitracin or erythromycin; this rarely achieves complete resolution, due to the inability of antibiotics to penetrate concretions
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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:
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Local abscess formation
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Subperiosteal abscess
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Orbital cellulitis
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Orbital abscess
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Intracranial extension of infection
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Periorbital cellulitis. This image shows an 8-year-old patient who presented with unilateral eyelid swelling and erythema.
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Acute dacryocystitis.
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Upper eyelid anatomy.
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Lower eyelid anatomy.
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Eye and lacrimal duct, anterior view.
