Orbital Cellulitis

What is it?

Bacterial or fungal infection of lids and orbital tissues
In children, usually arises from spread of infection from blocked and infected ethmoid sinus
In children or adults, may arise from infected lid skin wound
Otherwise rare in immune-competent, non-diabetic adults
In diabetic, elderly, and otherwise immune-compromised adults, fungal infection (aspergillosis, mucormycosis) must be considered
May be restricted to tissues in front of orbital septum ("pre-septal cellulitis") or, more dangerously, involve tissues behind orbital septum ("post-septal cellulitis")
Untreated infection may spread to intracranial space, leading to meningitis, cavernous sinus 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 (in "post-septal cellulitis")
Reduced vision (in "post-septal cellulitis")
Concurrent ethmoid sinusitis in children
Immune compromise, diabetes, vaso-occlusive process, face trauma, cancer in adults

Conjunctivitis, contact dermatitis, stye, dacryocystitis, orbital tumor, BUT...
Conjunctivitis causes more engorgement of conjunctival vessels and rarely much swelling of lids and orbital soft tissues
Contact dermatitis affects only lids and surrounding facial skin
Stye causes focal swelling and tenderness mainly affecting one lid
Dacryocystitis causes focal swelling and tenderness of nasal portion of lower lid, where lacrimal sac lies
Orbital tumor causes relatively more proptosis and less inflammation
Chronic conjunctivitis caused by autoimmune disease or chlamydia does not cause lid swelling
Anterior uveitis causes photophobia and no eyelid edema
Scleritis usually causes focal conjunctival redness, more periocular pain and less lid swelling
Idiopathic orbital inflammation, but orbital imaging should make distinction
Graves disease causes lid retraction and lag
Cavernous sinus arteriovenous fistula, which should have dilated superior ophthalmic vein on imaging

Order sino-orbital imaging studies to rule out sinusitis, orbital subperiosteal abscess, or tumor
In children, if imaging shows ethmoid sinusitis, treat with intravenous antibiotics aimed at streptococcus, staphylococcus
If no improvement within 2 days, surgical sinus drainage may be necessary
Subperiosteal abscess may require surgical orbital drainage
In adults, imaging and sinonasal biopsy aimed at diagnosing fungal infection, especially in immunocompromised hosts; treatment depends on findings

In immune-competent children with ethmoid sinusitis, systemic antibiotic treatment usually rapidly resolves all manifestations with no damage, but orbital abscess drainage and sinus surgery may be necessary
In adults, outcome depends on extent and type of infection and predisposing conditions