Peri-orbital and orbital cellulitis (OP)

Question 1

Define periorbital cellulitis.

Answer 1

Inflammation and infection of the superficial eyelid AKA pre-septal cellulitis

The inflammation remains confined to the soft tissue layers superficial to the orbital septum, and ocular function remains intact

Question 2

What can periorbital cellulitis lead to?

Answer 2

Orbital cellulitis

Question 3

Where does infection come from in periorbital cellulitis?

Answer 3

Superficial site of inoculation e.g. insect bite, chalazion, epidermal inclusion cyst, folliculitis

Question 4

Define orbital cellulitis.

Answer 4

Infection within the orbital soft tissues

May be associated with ocular dysfunction and usually due to underlying bacterial sinusitis

Question 5

What are some causes of orbital cellulitis?

Answer 5

• local spread of URTI especially sinusitis
• orbital injury
• fracture
• dacrocystitis, endophthalmitis (panophthalmitis), underlying dental infections

Question 6

Which out of periorbital and orbital cellulitis is more serious?

Answer 6

Orbital cellulitis is more serious and needs hospital admission (for IV Abx)

Question 7

Who is periorbital/orbital cellulitis more common in? (2)

Answer 7

• 2x more common in children than adults
• M>F

Question 8

What organisms cause orbital cellulitis? (4)

Answer 8

• Staphylococcus aureus
• Staphylococcus epidermis
• Streptococci spp
• anaerobes

Question 9

What are some risk factors for orbital cellulitis? (6)

Answer 9

• sinusitis / recent sinus infection
• young age (mean age 7-12)
• male sex
• lack of Hib vaccine in children
• recent eyelid injury e.g. insect bite on eyelid (periorbital cellulitis)
• ear or facial infection

Question 10

What are some general clinical features of periorbital/orbital cellulitis (bold = specific to orbital cellulitis)?

Answer 10

• visual impairments (e.g. diplopia, reduced acuity)
• ophthalmoplegia - pain with eye movements
• proptosis - bulging eye
• red, painful, swollen eye of acute onset
• eyelid oedema and erythema
• ocular pain

Question 11

What features are specific to orbital cellulitis? (3)

Answer 11

• visual impairments (e.g. diplopia, reduced acuity)
• ophthalmoplegia - pain with eye movements
• proptosis - bulging eye

Question 12

What might you see in periorbital cellulitis?

Answer 12

Insect bite on eyelid

Question 13

What feature might you see in orbital cellulitis with meningeal involvement (rare)?

Answer 13

Drowsiness +/- nausea and vomiting

Question 14

What would clinical examination involving ophthalmological assessment show in orbital cellulitis?

Answer 14

• decreased vision
• afferent pupillary defect
• proptosis
• dysmotility
• oedema
• erythema

Question 15

What scan do we do in all patients with suspected orbital cellulitis?

Answer 15

CT sinus and orbits with contrast –> inflammation of periorbital or orbital tissue to differentiate conditions + assess for posterior spread of infection + sinusitis

IV Abx given before CT done in suspected orbital cellulitis

Question 16

What might FBC show in orbital cellulitis?

Answer 16

Raised WBC and inflammatory markers

Question 17

Why would we do a blood culture and swab in orbital cellulitis?

Answer 17

To determine causative organism

(Most common bacterial causes: Streptococcus, S. aureus, H. influenzae B)

Question 18

What are some differential diagnoses for periorbital/orbital cellulitis? (3)

Answer 18

• orbital pseudotumour (no Sx infection)
• thyroid eye disease
• panophthalmitis (severe pain and decreased vision following intraocular surgery/foreign body)

Question 19

How do we manage periorbital cellulitis? (2)

Answer 19

• oral antibiotics (co-amoxiclav)
  
  • erythema multiforme
  • cholestasis
• secondary care referral

Question 20

What are some side effects of co-amoxiclav? (2)

Answer 20

• erythema multiforme (target lesions on back if hands/feet before spreading +/- pruritus)
• cholestasis

Question 21

How do we manage orbital cellulitis? (2)

Answer 21

• hospital admission (ENT review)
• IV antibiotics (vancomycin + cefotaxime) –> before doing CT

Question 22

What are some complications of orbital cellulitis?

Answer 22

• cavernous sinus thrombosis
• orbital abscess
• blindness
• brain abscess / epidural abscess
• (ocular empyema, ocular compartment syndrome, meningitis, death)

Question 23

Describe the prognosis of periorbital and orbital cellulitis.

Answer 23

• periorbital cellulitis improvement seen in 1-2 days
• orbital orbital cellulitis - lag time of 1-2 days between IV Abx and clinical response
  
  • if no response/new signs like decreased vision or RAPD, redo CT and suspect abscess formation or resistant organisms