Orbital cellulitis

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A blinding emergency, admit for intravenous antibiotics, computerised tomography, and prompt surgical attention to the source.

Infections around the eye can start from a scratch or similar lesion on an eyelid or nearby, or else can spread through from an adjacent sinus. Quickly, the eye can become injected, the swelling in the eyelids can make it impossible to open the eye, there can be accompanying fever and malaise. It is important however to distinguish an infection that has spread/emerged from behind the eye, which then may have the potential to form an abscess and to spread intracranially. Classically these two forms have been called periorbital and orbital, or else pre-septal and post-septal (Chandler's pathological classification[1]).
LogoKeyPointsBox.pngChandler’s classification[1] - Grade:
  1. Periorbital cellulitis (preseptal)
  2. Orbital cellulitis (postseptal)
  3. Subperiosteal abscess
  4. Intraorbital abscess
  5. Cavernous sinus thrombosis
Some argue for a simpler classification of:[2]
  1. Periorbital cellultitis
  2. Subperiosteal abscess
  3. Orbital abscess

The major features of post-septal infection are proptosis, painful eye movements, and ophthalmoplegia. Any of these findings justifies urgent CT with a view to surgical drainage.

In a retrospective study of children attending an emergency department, 50% of abscesses did not have these findings - multivariate analysis showed that other major risk factors were:[3]

  • neutrophils >10
  • absence of infectious conjunctivitis
  • periorbital (ie beyond eyelid) oedema

These factors had ORs in the range 5.9-8.6. Age >3yrs and previous antibiotic therapy were also significant but less so (OR 2.3-3.6). Fever is often not seen!

From sinus cultures, mostly streptococcus (viridans, Group A, pneumococcus) and staphylococcus (mostly non-aureus!), often multiple, occasional haemophilus. Treatment with penicillin/cefuroxime and flucloxacillin should cover most, additional anaerobic cover may be required. Nasal congestants often used.


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