What are recommendations for patients with Orbital Cellulitis?
Orbital cellulitis is an infection involving the contents of the orbit (fat and ocular muscles). Preseptal cellulitis and orbital cellulitis involve different anatomic sites, with preseptal cellulitis referring to infections of the soft tissues anterior to the orbital septum and orbital cellulitis referring to infections posterior to it . Although the two entities may initially be confused with one another, it is important to distinguish between them because they have very different clinical implications. Preseptal cellulitis is generally a mild condition that rarely leads to serious complications, whereas orbital cellulitis may cause loss of vision and even loss of life. Orbital cellulitis can usually be distinguished from preseptal cellulitis by its clinical features (ophthalmoplegia, pain with eye movements, and proptosis) and by imaging studies; in cases in which the distinction is not clear, clinicians should treat patients as though they have orbital cellulitis. Both conditions are more common in children than in adults.
●The most common underlying factor that leads to orbital cellulitis is acute sinusitis, particularly ethmoid sinusitis; less common causes are ophthalmic surgery and orbital trauma.
●Orbital cellulitis is often a polymicrobial infection. The most commonly identified pathogens in orbital cellulitis are Staphylococcus aureus and streptococci .
●The diagnosis of orbital cellulitis is suspected clinically and can be confirmed by contrast-enhanced computed tomography (CT) scanning of the orbits and sinuses. During the initial evaluation, it is critical to distinguish preseptal cellulitis from the more serious orbital cellulitis . It is also important to evaluate for complications of orbital cellulitis, such as subperiosteal abscess, orbital abscess, visual loss, and intracranial extension. Although both preseptal cellulitis and orbital cellulitis typically cause eyelid swelling with or without erythema, features such as ophthalmoplegia, pain with eye movements, and/orproptosis occur only with orbital cellulitis.
●The diagnosis of orbital cellulitis is made by a combination of physical examination findings (including formal assessments of extraocular movements, visual acuity, and proptosis), and radiologic assessment with CT scanning.
●We recommend that patients with suspected orbital cellulitis with any of the following features undergo a contrast-enhanced CT scan of the orbits and sinuses to confirm the diagnosis of orbital cellulitis and detect potential complications:
•Proptosis
•Limitation of eye movements
•Pain with eye movements
•Double vision
•Vision loss
•Edema extending beyond the eyelid margin
•Absolute neutrophil count (ANC) >10,000cell/microL
•Signs or symptoms of central nervous system (CNS) involvement
•Inability to examine the patient fully (usually patients less than one year of age)
•Patients who do not begin to show improvement within 24 to 48 hours of initiating appropriate therapy
●Complications of orbital cellulitis may develop rapidly and include subperiosteal and orbital abscesses, extension to the orbital apex causing vision loss, or intracranial extension causing epidural abscess or subdural empyema, intracranial abscess, meningitis, or cavernous sinus thrombosis.
●For patients with orbital cellulitis, we suggest initial empiric antibiotic treatment with parenteral broad-spectrum therapy with activity against S. aureus(including methicillin-resistant S. aureus [MRSA]), streptococci, and gram-negative bacilli; this should include vancomycin plus one of the following:ampicillin-sulbactam, piperacillin-tazobactam,ceftriaxone, or cefotaxime . If ceftriaxone or cefotaxime is employed and there is concern for intracranial extension, we suggest thatmetronidazole be added to the regimen to cover anaerobes .
●Signs and symptoms should begin to show improvement within 24 to 48 hours following the initiation of appropriate therapy; if this does not occur, repeat imaging should be performed and surgery should be considered.
●For patients with uncomplicated orbital cellulitis, we suggest that antibiotics be continued until all signs of orbital cellulitis have resolved, and for a total of at least two to three weeks (including both intravenous and oral therapy). A longer period (at least four weeks) is recommended for patients with severe ethmoid sinusitis and bony destruction of the sinus. The management of the complications of orbital cellulitis is discussed separately.
●Although initial treatment may consist of intravenous antibiotics alone, management should be in consultation with an ophthalmologist and an otolaryngologist because the physical examination requires ophthalmic and/or otolaryngologic expertise and surgery is sometimes required. The main indications for surgery are a poor response of the infection to antibiotic treatment, worsening visual acuity or pupillary changes, or evidence of an abscess, especially a large abscess (>10 mm in diameter) or one that fails to respond promptly to antibiotic treatment.
