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Orbital Infection

Orbital infection is a bacterial, viral or parasitic infection of tissues around the eyes. It can lead to a dramatic outcome and fast management of this infection is critical for the preservation of eyesight and prevention of possible meningitis.


Presentation

When orbital infection (OI) is suspected, patient history should be taken into account as some non-infectious etiologies can mimic the presentation of this disease. Hence, inquiries about recent insect stings, battles, trauma, allergies should be made. Furthermore, a survey about traveling, and any factors contributing to infection, like immunosuppressive medication use, chronic diseases is also significant. Patients with orbital infection may have had previous occasions of infections in structures anatomically close to the orbit e.g. a dental abscess or sinusitis. Likewise, respiratory system infections are known to be associated with OI [1].

Orbital infection is divided into five groups [2]:

  1. Preseptal cellulitis
  2. Orbital cellulitis
  3. Subperiosteal abscess
  4. Orbital abscess
  5. Cavernous sinus thrombosis

Each group manifests in individual ways. For instance, preseptal cellulitis affects eyelids, thus clinical presentation is inflammation of the eyelid with edema, warmth, pain, and erythema [3].

Orbital cellulitis (OC) exhibits as inflammation of fat tissue surrounding the globe. In this case, the edematous lid will not show signs of inflammation, as edema arises from disrupted venous outflow. Additionally, eyelids can show signs of palsy due to compression of the oculomotor nerve. Other signs of orbital cellulitis are chemosis, displacement of the orbit (proptosis), as well as disturbed vision [1].

Subperiosteal abscess clinically presents as proptosis, restricted mobility of the eye, and sensations of pain during motion [2].

Orbital abscess presents with more serious proptosis, in addition to ophthalmoplegia, and disturbed visual acuity. Palsy of abducens nerve is possible resulting in diplopia or double vision [2].

Cavernous sinus thrombosis is characterized by bilateral photophobia, proptosis, ophthalmoplegia, hypoesthesia of the cornea. Paresis or palsy of cranial nerves IV and VI are seen as well [4].

Severe cases of orbital infection can cause complications like meningitis, infarction of orbital structures such as the optic nerve, sclera, choroid and retina. Infarction may arise due to compression of surrounding arteries with mass lesions or inflammation [5]. Glaucoma, although a rare manifestation, can present in OI by interfering with visual acuity [6].

Soft Tissue Swelling
  • Characteristic findings are bilateral, boggy, nontender, nondiscolored soft-tissue swelling. Allergic inflammation includes angioneurotic edema or contact hypersensitivity. ( 2 ) Superficially, these problems can resemble acute infection.[pedsinreview.aappublications.org]
  • You also notice soft tissue swelling and redness around her left eye. And when you look at Irena in profile, you notice that her left eye protrudes anteriorly from the orbit.[coursera.org]
Localized Edema
  • Hypoproteinemia and congestive heart failure cause eyelid swelling due to local edema. Characteristic findings are bilateral, boggy, nontender, nondiscolored soft-tissue swelling.[pedsinreview.aappublications.org]
Congestive Heart Failure
  • Hypoproteinemia and congestive heart failure cause eyelid swelling due to local edema. Characteristic findings are bilateral, boggy, nontender, nondiscolored soft-tissue swelling.[pedsinreview.aappublications.org]
Soft Tissue Mass
  • Orbital cellulitis poor definition of orbital planes inflammatory stranding in the intraconal fat intraconal or extraconal soft tissue mass edema of the extraocular muscles intraorbital abscess subperiosteal abscess Endophthalmitis Findings are often[radiopaedia.org]
Heart Failure
  • We report the first case of a fatal N. mangiferae orbital infection following a thorn penetration injury in a patient who also had diabetes mellitus, heart failure, and cirrhosis.[ncbi.nlm.nih.gov]
  • Hypoproteinemia and congestive heart failure cause eyelid swelling due to local edema. Characteristic findings are bilateral, boggy, nontender, nondiscolored soft-tissue swelling.[pedsinreview.aappublications.org]
Eye Pain
  • If you’re experiencing any eye pain or vision problems, your doctor may order blood tests and take blood samples. An infection in your eye can cause serious complications.[healthline.com]
  • pain Tenderness to touch of lids Mildly engorged conjunctival vessels Proptosis (in "post-septal cellulitis") Reduced eye movements (in "post-septal cellulitis") Diplopia (in "post-septal cellulitis") Reduced vision (in "post-septal cellulitis")[kellogg.umich.edu]
  • Signs and Symptoms Fever – generally 102 F or higher Painful swelling of upper and lower lids (upper is usually greater) Eyelid appears shiny, taut and is reddish or purplish in color Restricted eye movements Eye pain, especially with movement Eye burning[diagnose-me.com]
  • Signs and symptoms include swelling and pain of the eyelids, pain in the eye, painful eye movements, decreased vision, and fever. It is a serious condition that requires immediate medical attention.[fpnotebook.com]
  • Factors that increase the risk of getting orbital cellulitis include having: Severe sinus or tooth infections Infection of the bloodstream Injury or surgery in the area Symptoms Symptoms of orbital cellulitis include: Bulging eye Painful eye movements[cancercarewny.com]
Diplopia
  • Palsy of abducens nerve is possible resulting in diplopia or double vision. Cavernous sinus thrombosis is characterized by bilateral photophobia, proptosis, ophthalmoplegia, hypoesthesia of the cornea.[symptoma.com]
  • […] thrombosis Diffuse, balloon-like swelling and violet discoloration of upper and lower lids Eye pain Tenderness to touch of lids Mildly engorged conjunctival vessels Proptosis (in "post-septal cellulitis") Reduced eye movements (in "post-septal cellulitis") Diplopia[kellogg.umich.edu]
  • She also noticed diplopia in all gazes. She initially presented to her pediatrician who thought she had a preseptal cellulitis and started her on amoxicillin.[webeye.ophth.uiowa.edu]
  • Pseudotumor/Idiopathic orbital inflammatory disease/ Non-specific orbital inflammatory disease  Presents as proptosis,pain, diplopia, lid swelling and redness  Usually unilateral but occasionally bilateral.  Ultrasonography ofthe orbit shows a diffuse[slideshare.net]
  • The clinical signs are fever, pain, proptosis, redness, swelling of the lid and orbital tissue and restricted eye movements which may occasionally lead to diplopia and, as the condition worsens, visual acuity decreases.[medical-dictionary.thefreedictionary.com]
Strabismus
  • B Adjunct therapy: hyperbaric oxygen therapy may possibly be beneficial Orbital cellulitis infectious inflammatory process involving the orbital tissues posterior to the orbital septum and requires Etiologies include trauma, orbital fracture repair, strabismus[drmansueto.com]
  • Surgical procedures, including orbital decompression, dacryocystorhinostomy, eyelid surgery, [3] strabismus surgery, retinal surgery, and intraocular surgery, have been reported as the precipitating cause of orbital cellulitis.[emedicine.medscape.com]
  • Post-surgery - including orbital, lacrimal, strabismus and vitreoretinal surgery. Haematogenous spread from distant bacteraemia.[patient.info]
  • The patient may have strabismus and subsequent diplopia due to the restriction of extraocular muscle movement. In severe cases, the patient may have optic neuropathy with a relative afferent pupillary defect.[healio.com]
Unilateral Proptosis
  • Clinically, all patients presented with unilateral proptosis, periorbital edema and tenderness, and restriction of ocular motility. Fever was absent in 39.2% of patients.[joii-journal.springeropen.com]
Unilateral Ptosis
  • Signs include unilateral ptosis, proptosis, visual loss, internal and external ophthalmoplegia (ie, palsy of the pupillary and extraocular muscles), and CN V1 (forehead) anesthesia.[emedicine.medscape.com]
Facial Swelling
  • The patient was clinically doing better with decreased eye and facial swelling, and his erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were decreased to normal values.[ncbi.nlm.nih.gov]
  • On examination, the facial swelling was brawny hard with marked cellulitis.[sciforschenonline.org]
  • Therefore, in our part of the world morbidity and mortality is even higher and disease being more lethal than what is reported in western literature.4 Case Report A 40 year old man, smoker with no past co-morbids presented to ER with left facial swelling[jpma.org.pk]

Workup

For workup of orbital infection, radiologic investigations are essential to visualize the lesions, their localization, severity and spread to nearby tissues. Computed tomography (CT) scan of the orbit, sinuses, and frontal lobe is one of the primary modalities for diagnosis. Contrast is commonly used to exclude the presence of artifacts. In pediatric patients, it is important to lower the dose of radiation [7] by choosing magnetic resonance imaging (MRI) over CT scan.

MRI scan is less cost-effective but more specific in investigating the soft tissues, specifically those that are infected. Also, MRI creates the possibility to visualize the spread of the orbital lesion and is better in distinguishing the cavernous sinus [8]. To further increase accuracy rate of the MRI, a contrast enhanced scan (gadolinium-based intravenous contrast) is used, particularly if there is high suspicion of infectious advancement deeper into anatomical structures [9]. T1-weighted imaging typically exposes infiltrations into periorbital fat if they exist. On the other hand, T2-weighted imaging distinguishes infectious lesions that are identified by hyperintense properties [10] [11]. MRI findings also include abscess masses, a presence of inflammation marked by enhanced eyelids and soft tissues of the orbit [11].

Laboratory studies comprise blood glucose level, complete blood count, as well as cerebrospinal fluid (CSF) analysis if meningitis is suspected. In presence of fever, a blood sample for possible leukocytosis must be obtained [10] [6].

Iron Increased
  • 0.0 % 2-9: 0.0 % 10-19: 0.0 % 20-29: 0.0 % 30-39: 0.0 % 40-49: 0.0 % 50-59: 0.0 % 60 : 100 % Top conditions involved for these people *: Arteriosclerosis Coronary Artery (thickening and hardening of arteries- coronary artery): 4 people, 100.00% Blood Iron[ehealthme.com]
Creatinine Increased
Eikenella
  • Ophthalmic infection with Eikenella species is even more unusual, but can be severe.[journals.lww.com]
  • Pseudomonas, Klebsiella, Eikenella, and Enterococcus are less common culprits. Polymicrobial infections with aerobic and anaerobic bacteria are more common in patients aged 16 years or older.[emedicine.medscape.com]

Treatment

  • Early diagnosis may lead to a successful treatment and good prognosis.[ncbi.nlm.nih.gov]
  • In light of our increased knowledge of sinusitis, improved diagnostic tools, and new pharmacologic and surgical treatments, we investigated whether trends in diagnosis and treatment are changing.[ncbi.nlm.nih.gov]
  • There is no standard treatment for entomophthoramycosis. Our patient responded well to combined antifungal therapy without aggressive surgical débridement.[ncbi.nlm.nih.gov]
  • Treatment included surgical drainage of the resulting subperiosteal orbital abscess through a Caldwell-Luc approach as well as aggressive antibiotic therapy. The importance of early suspicion of this entity and its potential sequelae are discussed.[ncbi.nlm.nih.gov]
  • Cellulitis may be managed by antibiotic treatment alone, but if an abscess is present it should be drained immediately with a formal ethmoidectomy to decompress the orbit if there is any evidence of reduced visual acuity.[ncbi.nlm.nih.gov]

Prognosis

  • The case highlights the difficulty in recognising orbital collections when venous engorgement secondary to a cavernous sinus thrombosis coexists and demonstrates how the prognosis has been improved through antibiotics, anticoagulation and timely surgical[ncbi.nlm.nih.gov]
  • Early diagnosis may lead to a successful treatment and good prognosis.[ncbi.nlm.nih.gov]
  • Key findings include : T2 FLAIR: high signal DWI/ADC: diffusion restriction in the affected globe Treatment and prognosis Periorbital cellulitis is treated with oral antibiotics. Orbital cellulitis is treated with intravenous antibiotics.[radiopaedia.org]
  • Prognosis; Complications; Seek medical attention if... With early recognition and treatment the patient can be expected to recover fully.[diagnose-me.com]
  • He based his classification on the anatomy of orbit, perceived progression of infection, responsiveness to treatment and general prognosis. Chandler fine tuned this classification system and made it more acceptable.[sites.google.com]

Etiology

  • PredisORALsing factors: patients who have diabetic ketoacidosis or who are immunocompromised Etiology: Infection begins in the paranasal sinuses and spreads to the orbit. The large, nonseptate hyphae cause vascular occlusion.[drmansueto.com]
  • For each disorder, the etiology, clinical manifestations, imaging characteristics, differential diagnoses, and management options are described and discussed.[books.google.com]
  • When orbital infection (OI) is suspected, patient history should be taken into account as some non-infectious etiologies can mimic the presentation of this disease.[symptoma.com]
  • These infections typically present in children and young adults but can affect any age group. proptosis painful ophthalmoplegia chemosis reduced visual acuity Etiology Periorbital cellulitis often results from contiguous spread of an infection of the[radiopaedia.org]
  • […] time-saving ability of emergency bed side ultrasound diagnosis of elevated intracranial pressure (ICP) via measurement of the optic nerve diameter. [4] Recent literature suggests this same modality can be used in diagnosing papilledema from a non-ICP etiology[emedicine.medscape.com]

Epidemiology

  • Orbital Cellulitis Epidemiology : All age groups are affected, but average age is 6.8. It affects males twice as often.[pedclerk.bsd.uchicago.edu]
  • Jump to: navigation, search Orbital cellulitis Microchapters Home Patient Information Overview Historical Perspective Classification Pathophysiology Causes Differentiating Orbital cellulitis from other Diseases Epidemiology and Demographics Risk Factors[wikidoc.org]
  • "Epidemiological characteristics of orbital cellulitis among adult population in the Split region, Croatia". Wiener Klinische Wochenschrift. doi : 10.1007/s00508-018-1402-4. ISSN 0043-5325. PMID 30374774. Noel LP, Clarke WN, MacDonald N (1990).[en.wikipedia.org]
  • Orbital cellulitis Preseptal cellulitis Mixed flora Include gram positives, gram negatives, anaerobes Usually GAS or staph Requires broad spectrum antibiotics Treat with narrow spectrum antibiotics Vision risk Rarely spreads into eye if treated Epidemiology[lecturio.com]
  • Epidemiology Orbital cellulitis is much less common than preseptal cellulitis although data relating to the incidence are scant.[patient.info]
Sex distribution
Age distribution

Pathophysiology

  • […] the orbital tissues posterior to the orbital septum and requires Etiologies include trauma, orbital fracture repair, strabismus surgery Extension of pre-existing infections of the face, lacrimal sac, and lacrimal gland which can extend into the orbit Pathophysiology[drmansueto.com]
  • An understanding of this anatomical relationship (see the image below) is key to appreciating the pathophysiology of orbital infections. Lamina papyracea.[emedicine.medscape.com]
  • Jump to: navigation, search Orbital cellulitis Microchapters Home Patient Information Overview Historical Perspective Classification Pathophysiology Causes Differentiating Orbital cellulitis from other Diseases Epidemiology and Demographics Risk Factors[wikidoc.org]
  • Orbital cellulitis: pathophysiology [ 2 ] Orbital cellulitis occurs when infection develops in the postseptal orbit, through local or haematogenous spread.[patient.info]
  • Pathophysiology of Preseptal and Orbital Cellulitis Patients can develop preseptal cellulitis due to direct extension of infected paranasal sinuses to tissues anterior to the orbital septum.[lecturio.com]

Prevention

  • Awareness of this possible complication followed by appropriate early intervention will prevent a potentially blinding condition.[ncbi.nlm.nih.gov]
  • In the literature, only anecdotal reports and inconclusive studies address this problem, and its possible prevention.[ncbi.nlm.nih.gov]
  • It can lead to a dramatic outcome and fast management of this infection is critical for the preservation of eyesight and prevention of possible meningitis.[symptoma.com]
  • Supported in part by a Challenge Grant from Research to Prevent Blindness, Inc., New York, New York, U.S.A., to the University of West Virginia Department of Ophthalmology (Judie Charlton, M.D., Chairman).[journals.lww.com]
  • […] infection, or endogenous w/septic embolization fever, proptosis, restriction of EOM’s, pain on globe movement decreased visual acuity Afferent Pupillary Defect (APD), prolonged high Intraocular pressure (IOP) can be indications for aggressive management to prevent[drmansueto.com]

References

Article

  1. Chaudhry IA, Shamsi FA, Elzaridi E, et al. Outcome of treated orbital cellulitis in a tertiary eye care center in the middle East. Ophthalmology. 2007;114:345–54.
  2. Chandler JR, Langenbrunner DJ, Stevens ER. The pathogenesis of orbital complications in acute sinusitis. Laryngoscope 1970;80:1414–28.
  3. Chaudhry IA, Shamsi FA, Elzaridi E, Al-Rashed W, Al-Amri A, Arat YO. Inpatient preseptal cellulitis: experience from a tertiary eye care centre. Br J Ophthalmol. 2008;92:1337–41.
  4. Visvanathan V, Uppal S, Prowse S. Ocular manifestations of cavernous sinus thrombosis. BMJ Case Rep. 2010;2010:bcr0820092225.
  5. Lutt JR, Lim LL, Phal PM, Rosenbaum JT. Orbital inflammatory disease. Semin Arthritis Rheum. 2008;37:207–222.
  6. Chaudhry IA, Al-Rashed W, Arat YO. The Hot Orbit: Orbital Cellulitis. Middle East Afr J Ophthalmol. 2012;19(1):34-42.
  7. Mills DM, Tsai S, Meyer DR, Belden C. Pediatric ophthalmic computed tomographic scanning and associated cancer risk. Am J Ophthalmol. 2006 Dec;142(6):1046-53.
  8. Younis RT, Anand VK, Davidson B. The role of computed tomography and magnetic resonance imaging in patients with sinusitis with complications. Laryngoscope. 2002 Feb;112(2):224-9.
  9. Parmar H, Gandhi D, Mukherji, SK, Trobe JD. Restricted Diffusion in the Superior Ophthalmic Vein and Cavernous Sinus in a Case of Cavernous Sinus Thrombosis. J Neuro-Ophthalmol. 2009;29;1:16-20.
  10. Kapur R, Sepahdari AR, Mafee MF, Putterman AM, Aakalu V, Wendel LJ, Setabutr P. MR imaging of orbital inflammatory syndrome, orbital cellulitis, and orbital lymphoid lesions: the role of diffusion-weighted imaging. AJNR Am J Neuroradiol. 2009;30:64–70.
  11. Pakdaman MN, Sepahdari AR, Elkhamary SM. Orbital inflammatory disease: Pictorial review and differential diagnosis. World J Radiol. 2014;6(4):106-115.

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Last updated: 2019-07-11 21:38