Role of inflammation in orbital cellulitis

Bacterial orbital cellulitis - A review

Infections of orbit and periorbita are frequent, leading to significant morbidity. Orbital cellulitis is more common in children and young adults. At any age, infection from the neighboring ethmoid sinuses is a likely cause and is thought to result from anatomical characteristics like thin medial wall, lack of lymphatics, orbital foramina, and septic thrombophlebitis of the valveless veins between the two. Other causes are trauma, orbital foreign bodies, preexisting dental infections, dental procedures, maxillofacial surgeries, Open Reduction and Internal Fixation (ORIF), and retinal buckling procedures. The septum is a natural barrier to the passage of microorganisms. Orbital infections are caused by Gram-positive, Gram-negative organisms and anaerobes in adults and in children, usually by Staphylococcus aureus or Streptococcus species. Individuals older than 15 years of age are more likely to harbor polymicrobial infections. Signs include diffuse lid edema with or without erythema, chemosis, proptosis, and ophthalmoplegia. It is an ocular emergency requiring admission, intravenous antibiotics, and sometimes surgical intervention. Computed tomography (CT) and magnetic resonance imaging (MRI) are the main modalities to identify the extent, route of spread from adjacent structures, and poor response to intravenous antibiotics and to confirm the presence of complications. If orbital cellulitis is secondary to sinus infection, drainage of pus and establishment of ventilation to the sinus are imperative. Loss of vision can occur due to orbital abscess, cavernous sinus thrombosis, optic neuritis, central retinal artery occlusion, and exposure keratopathy, and possible systemic sequelae include meningitis, intracranial abscess, osteomyelitis, and death. The article was written by authors after a thorough literature search in the PubMed-indexed journals.

High risk and low prevalence diseases: Orbital cellulitis

INTRODUCTION

Orbital cellulitis is an uncommon but serious condition that carries with it a potential for significant morbidity.

OBJECTIVE

This review highlights the pearls and pitfalls of orbital cellulitis, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Orbital cellulitis refers to infection of the globe and surrounding soft tissues posterior to the orbital septum. Orbital cellulitis is typically caused by local spread from sinusitis but can also be caused by local trauma or dental infection. It is more common in pediatric patients compared to adults. Emergency clinicians should first assess for and manage other critical, sight-threatening complications such as orbital compartment syndrome (OCS). Following this assessment, a focused eye examination is necessary. Though orbital cellulitis is primarily a clinical diagnosis, computed tomography (CT) of the brain and orbits with and without contrast is critical for evaluation of complications such as abscess or intracranial extension. Magnetic resonance imaging (MRI) of the brain and orbits with and without contrast should be performed in cases of suspected orbital cellulitis in which CT is non-diagnostic. While point-of-care ultrasound (POCUS) may be useful in differentiating preseptal from orbital cellulitis, it cannot exclude intracranial extension of infection. Management includes early administration of broad-spectrum antibiotics and ophthalmology consultation. The use of steroids is controversial. In cases of intracranial extension of infection (e.g., cavernous sinus thrombosis, abscess, or meningitis), neurosurgery should be consulted.

CONCLUSION

An understanding of orbital cellulitis can assist emergency clinicians in diagnosing and managing this sight-threatening infectious process.

Fifteen-minute consultation: Preseptal and orbital cellulitis

'It is midnight and you are called to see a thirteen-year-old boy who has been brought to the paediatric emergency department with a 24-hour history of swelling and redness of his left eye. He has had a 'runny nose' for a couple of days. He is systemically well. His upper and lower lids are red and swollen such that his eye is not open fully, though you elicit normal eye movements when you open his eye. Pupils are equal and reactive with no afferent pupillary defect. Visual acuity and colour vision are normal on examination.' In this article, we consider the approach to preseptal and orbital cellulitis in children including the initial assessment and management options.

Blindness resulting from orbital complications of ophthalmic zoster

Herpes zoster ophthalmicus occurs when the latent varicella zoster virus (VZV) reactivates in the trigeminal ganglion and ophthalmic branch of the trigeminal nerve. In the elderly, there is a sharp increase in the tendency of secondary skin bacterial infections occurrence due to the deterioration of capabilities of self-care and changed sanitation. We present a case of patient who developed phlegmon of the orbit, which resulted with complete unilateral blindness. Varicella zoster virus infection in the elderly may have a severe course due to the progressive weakening of the immune system related to the age. Moreover, skin lesions around the eye socket require special care in prevention of bacterial superinfections due to the extremely high risk of life-threatening complications or disability. Neuralgia resistant to pharmacological treatment present in the course of ophthalmic zoster and difficulty in caring about skin lesions predispose to the occurrence of complications.

Update in pathological diagnosis of orbital infections and inflammations

Orbital infections and inflammations include a broad spectrum of orbital diseases that can be idiopathic, infectious, from primary or secondary inflammatory processes. Being able to properly diagnose and manage these orbital diseases in a timely manner can avoid permanent vision loss and possibly save a patient's life. When clinicians are faced with such patients, quite often the exact diagnosis cannot be made just based on clinical examination, various laboratory tests and imaging are needed. Moreover, orbital biopsies with histopathological analyses are often required, especially for the atypical cases. Thus, it is important for the clinicians to be familiar with the pathological features and characteristics of these orbital diseases. This review provides a comprehensive update on the clinical and pathological diagnosis of these orbital infections and inflammations.

Understanding pediatric bacterial preseptal and orbital cellulitis

Pediatric preseptal and orbital cellulitis are infectious disorders that result in periorbital inflammation. Preseptal cellulitis is often associated with breaches in the skin barrier whereas orbital cellulitis is commonly associated with paranasal sinusitis. Orbital cellulitis may be associated with subperiosteal abscess. It is important to distinguish between preseptal from orbital cellulitis. Clinical examination and diagnostic imaging are useful in determining appropriate management. Patients are usually treated with broad spectrum antibiotics and surgery when indicated.

Headache attributable to disorders of the eye

Sensory innervation to the eye and periocular area arises from the ophthalmic branch of the trigeminal nerve. Thus, ocular, orbital, and systemic disorders may produce head pain with ocular signs and symptoms. Whereas some of these entities have characteristic diagnostic features, others mimic primary headache disorders such as migraine and cluster headache. This article reviews common ocular and neuro-ophthalmic conditions that are accompanied by pain in or near the eye.

Forget me not

A 37-year-old man presented with a facial abscess that progressed to external ophthalmoplegia and proptosis. Neuroimaging was consistent with cavernous sinus thrombosis. The diagnosis, management options, and management controversies of septic cavernous sinus thrombosis are discussed, including neuroimaging, antibiotic choice, and the role of corticosteroids and anticoagulation.

Odontogenic orbital cellulitis

PURPOSE

To describe a small series of patients with odontogenic orbital cellulitis and review the visual outcomes of such patients reported in the scientific literature.

METHODS

Review of medical records and the scientific literature. Measured parameters included gender, age, days to presentation and surgery, the need for surgical intervention(s), sinus and orbital involvement on CT imaging, and pathogens involved.

RESULTS

Current cases and review of the scientific literature resulted in 24 patients with odontogenic orbital cellulitis and adequate examinations for statistical analysis. Twelve of 24 patients had preserved vision (final vision better than 20/70), whereas 11 of 24 patients had vision loss (final vision of light perception or no light perception). Analysis of data showed no statistical correlation between visual loss and age (p = 0.81), days to clinical presentation (p = 0.45), days to surgical exploration (p = 0.96), sinus radiographic involvement (p = 0.50), orbital radiographic findings (p = 0.19), or type of bacterial infection (Gram-positive aerobic vs. anaerobic organisms), (p = 0.31 and p = 0.50 respectively). Male gender, the need for surgical drainage, and multiple surgical procedures performed correlated statistically with loss of vision (p = 0.05, p = 0.03, and p = 0.02, respectively).

CONCLUSIONS

Multiple case reports have demonstrated that orbital cellulitis from an odontogenic source can result in devastating visual loss. Male gender, the need for surgical drainage, and multiple surgical procedures correlated statistically with severity of visual loss.

Periocular infection

PURPOSE OF REVIEW

The aim of this article is to acquaint the clinician with advances in the diagnosis and management of periocular cellulitis and to alert physicians to emerging pathogens.

RECENT FINDINGS

The most important, recent infectious disease entity to consider is community-acquired methicillin-resistant Staphylococcus aureus, which is emerging as a significant problem across the country. The potential devastation caused by necrotizing fasciitis is also reviewed, since this diagnosis is easily missed early in its course. A variety of less common and frankly atypical pathogens is presented to remind the clinician that, on occasion, the hoofbeats are indeed a zebra's.

SUMMARY

Periocular cellulitis remains an important and common entity in ophthalmology. The emergence of new pathogens and the resistance to conventional treatment by others are a cause for concern and require an understanding of management strategies.