CALIDAD DE VIDA

Most cellulitis involves the preseptal eyelid tissue. Orbital cellulitis represents an acute infection with infl ammation

of orbital contents, oft en including the pre- and postsep- tal eyelids [2, 6, 20, 44]. Periorbital cellulitis can be classi- fi ed into fi ve stages. Th e fi rst stage is preseptal cellulitis, in which infl ammatory edema remains anterior to the orbital septum. Th e second stage is posterior spread of this infl ammation, behind the arcus marginalis, to a true orbital cellulitis (infl ammation of the orbital contents without abscess formation). Th ird, subperiosteal abscesses may form, in which pus collects between the orbit and the periosteum of the involved sinus. Th e fourth stage is an orbital abscess, and the fi ft h involves cavernous sinus thrombosis [6, 24]. Th e course of treatment varies based on several factors, including the stage of the infection, the source of the infection, the health of the patient, and the underlying organism involved.

By and large, symptomatology and presentation of cel- lulitis vary with stage of disease. Th erefore, a patient with a swollen eyelid can present a challenge but may be read- ily diagnosed by careful clinical history, examination, and potentially necessary imaging modalities. Stage 1 disease, or preseptal cellulitis, typically presents as tender ery- thema of the upper or lower eyelids, with no orbital involvement (Fig. 10.1). Since this infl ammation is not restricted by the arcus marginalis, it may spread around the eye to involve both the upper and lower lids as well as the cheek and forehead. Th e history oft en includes a

Management of Periorbital Cellulitis

in the 21st Century

Michael P. Rabinowitz and Scott M. Goldstein

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Core Messages

Periorbital cellulitis can be a serious infection and ■

must be promptly recognized and treated. Due to vaccines and antibiotic use in the twenti- ■

eth century, the microbiologic spectrum of bacte- ria causing infections in the periorbital area in the twenty-fi rst century is diff erent from 10–15 years ago.

Methicillin-resistant

■ Staphylococcal aureus (MRSA)

infections are now a common entity and are aggres- sive.

Clinical examination and computed tomographic ■

(CT) scans are the two important aspects of prop- erly evaluating patients with infections.

A combination of medical antibiotic therapy and ■

surgical intervention is oft en needed to appropri- ately treat these infections, especially in teenagers and adults.

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concurrent sty, recent trauma, or sometimes nothing that the patient can recall. Examination oft en demonstrates lid pathology with a focal hordeolum or innocuous injury and surrounding edema and erythema that is oft en ten- der and warm to the touch. Proptosis, restricted motility, diplopia, vision changes, pupillary defects, or other optic nerve complications will be absent.

Orbital cellulitis, however, represents a more severe ophthalmic condition with signifi cant morbidity, includ- ing the possibility of blindness from optic nerve compres- sion or invasion and even mortality (Fig. 10.2a, b) [10, 13, 43, 48, 49]. When infection and infl ammation extend posterior across the orbital septum, edema of the orbit and associated increased orbital pressure provide for

associated proptosis, limited ocular motility, or visual disturbances [7, 24, 35]. As the stages of orbital cellulitis become more advanced, symptoms worsen, and diplopia, orbital congestion, and infl ammation will arise. As the orbital pressure increases, focal abscesses enlarge, and the optic nerve becomes more compromised. Abnormal pupillary refl exes, ophthalmoplegia, impaired color vision, and more severe visual loss may arise. More exten- sive spread may elicit proptosis, meningismus, altered mental status, headaches, and other signs indicative of cavernous sinus, meningitic, encephalitic, or systemic involvement. Th ese symptoms are fairly specifi c for advanced orbital cellulitis.

Fig. 10.1 Patient with 2 days of progressive swelling and dis- comfort in the right upper eyelid. Note the eye is white and quiet, and there is normal motility

a b

Fig. 10.2 (a, b) Patient with 5 days of upper respiratory infection developed sudden swelling and pain of left eye in 24-hr period. Note erythema, edema, proptosis, chemosis, ophthalmoplegia, and nasal discharge. CT scan demonstrates severe left -sided rhinitis, pan sinusitis, and extension of the infection into the medial left orbit. Note the gas in the anterior ethmoids and orbit

Summary for the Clinician

Orbital cellulitis represents an acute infection ■

with infl ammation of orbital contents, oft en including the pre- and postseptal eyelids Periorbital cellulitis can be classifi ed into fi ve ■

stages.

Th e fi rst stage is preseptal cellulitis, in which ■

infl ammatory edema remains anterior to the orbital septum.

Th e second stage is posterior spread of this ■

infl ammation, behind the arcus marginalis. In the third stage, subperiosteal abscesses may ■

form as pus collects between the orbit and the periosteum of the involved sinus.

Th e fourth stage is an orbital abscess. ■

Th e fi ft h involves cavernous sinus thrombosis. ■

It is good that most patients present with an early stage that will advance, if untreated, to later stages. However, there is no exact correlation between extent of cellulitis and clinical presentation. Further, patients do not neces- sarily progress stage by stage. Last, lab work is historically ineff ective in establishing or aiding a diagnosis [26, 35, 37]. Cultures are positive only 50% of the time, blood cul- tures are typically negative without underlying bactere- mia, and white blood cell counts and c-reactive protein levels are usually unreliable [23, 35]. Th at stated, any abscess or conjunctival discharge that can potentially be cultured should be.