Pediatric emergency medicine trisk 1010

FIGURE 123.3 Desmarres lid retractors (A ) or eye lid speculum (B ) can be helpful in opening
the eye lids if the child is unable or unwilling to open their eyes.

COMMON EYE EMERGENCIES
Periorbital and Orbital Cellulitis
CLINICAL PEARLS AND PITFALLS


Periorbital cellulitis most often results from some form of soft tissue
trauma or spread of local infection and can be managed with oral
antibiotics targeting common skin flora.
Orbital cellulitis is a vision-threatening infection that is characterized by
pain or limitation of eye movement, optic nerve involvement, and/or
proptosis.
Distinguishing between periorbital and orbital involvement is often
difficult based on clinical observations alone; imaging may play a
critical role in the diagnosis.
Many cases of orbital cellulitis can be managed medically with
intravenous (IV) antibiotics, whereas others may require surgical
intervention.
Current Evidence
The orbital septum is an extension of periosteum from the orbital bones that
inserts into the tarsal plate of the upper and lower lids to form the anterior
boundary of the orbital compartment. Periorbital (or preseptal) cellulitis refers to
infections limited to the soft tissues anterior to the orbital septum. Disease
processes posterior to the septum involve the contents of the orbit (e.g., fat,
nerves, and extraocular muscles) and cause orbital (or postseptal) cellulitis.
Involvement of the orbit can threaten vision and potentially result in spread to the
cavernous sinus and central nervous system (CNS).
Periorbital infections are usually secondary to skin pathogens and most often
result from eyelid trauma, insect bite, or contiguous spread of an infection, such

as conjunctivitis (especially neonatal gonococcal conjunctivitis) or dacryocystitis.
Periorbital cellulitis can however also be caused by underlying sinusitis. Orbital
cellulitis is most often caused by extension of infection from adjacent sinuses
(sinusitis is present in up to 98% of cases). Other etiologies include orbital trauma
and surgery, and infections of the teeth, ear, or face.
Periorbital cellulitis requires treatment with antibiotics targeting gram-positive
organisms since staphylococcal and streptococcal species are the most likely
causes (Staphylococcus aureus and Streptococcus pyogenes predominate when
infection arises from local skin trauma, whereas Streptococcus pneumoniae is
commonly associated with sinusitis). While the same organisms are often
involved in orbital cellulitis, nontypeable H. influenzae and other gram-negative
bacilli such as Moraxella catarrhalis are still important causes of orbital
complications of acute bacterial sinusitis. Anaerobes must also be considered


when there is concern for sinusitis, an odontogenic source, or proven or suspected
intracranial extension.
Goals of Treatment
Accurate identification of periorbital versus orbital cellulitis is essential to proper
treatment and a favorable clinical outcome. Timely administration of appropriate
antibiotics is critical in all cases. Prompt recognition of symptoms and
appropriate use of imaging allows for early diagnosis of orbital cellulitis, a
potentially vision- and life-threatening condition. Ophthalmology consultation is
indicated in all cases of suspected or proven orbital cellulitis. Surgical
intervention may be required. Otolaryngology consultation should be sought
when there is concurrent sinonasal pathology.

FIGURE 123.4 Periorbital cellulitis in a child with eyelid swelling, erythema, and tenderness.

Clinical Considerations

Clinical Recognition. Both periorbital and orbital cellulitis are more often seen in
children than adults. Both conditions commonly present with fever, and
periorbital erythema, pain, and swelling ( Fig. 123.4 ). Any pediatric patient who
presents with these findings requires careful examination to rule out orbital
cellulitis. The clinician should also recognize the signs of local and systemic


spread of infection including visual disturbances, altered mental status, and
sepsis.
Clinical Assessment. The primary concern when making the diagnosis of
periorbital cellulitis is to rule out the possibility of orbital cellulitis. The cardinal
signs of orbital cellulitis include decreased or painful eye movement, proptosis,
changes in vision (e.g., change in acuity, decreased color vision, or visual field
deficits), and papilledema (or other signs of optic nerve involvement such as
Marcus Gunn pupil). Patients with orbital cellulitis may be irritable, toxic, and
have a fever, but the presence of fever and leukocytosis are not sensitive enough
markers to discriminate between the two conditions. Due to the presence of the
orbital septum which acts as a structural barrier, the eyelid swelling of orbital
cellulitis typically does not extend beyond the superior orbital rim onto the brow.
The ED clinician should be aware that acute periorbital edema and erythema
can also occur without infection. Insect bites and allergic reactions can cause
dramatic acute periorbital swelling, typically with minimal induration or
tenderness, and oftentimes with pruritus. These conditions are not usually
associated with fever. Often, close inspection of the skin with magnification can
localize a site of an insect bite. Swelling related to systemic allergic reactions is
often bilateral, whereas periorbital cellulitis is rarely bilateral. Underlying
sinusitis can also cause periorbital swelling without cellulitis. Conditions which
may mimic some of the physical findings of orbital cellulitis include orbital
tumors (e.g., rhabdomyosarcoma, neuroblastoma), orbital pseudotumor (an
immune-mediated process), leukemia, and sickle cell crisis. The best way to

differentiate these mimickers of orbital cellulitis is with CT or MRI of the orbits
and sinuses.