orbital cellulitis

1. ORBITAL CELLULITIS
Presented By
Dr. Ankush D

2. ORBITAL CELLULITIS
• Orbital cellulitis is inflammation of
eye tissues behind the orbital
septum
• Refers to an acute spread of
infection into the eye socket from
either the adjacent sinuses or
through the blood
• When it affects the rear of the eye,
it is known as retro-orbital
cellulitis

3. INTRODUCTIO
N
CHANDLER CLASSIFICATION
Group 1 Pre-septal Cellulitis
Group 2 Orbital Cellulitis
Group 3 Subperiosteal abscess
Group 4 Orbital abscess
Group 5 Cavernous sinus thrombosis
Chandler classified the orbital complications of sinusitis in
devising effective treatment modalities.

4. Group I- Preseptal Cellulitis
 This is an inflammatory oedema anterior to the orbital
septum
 Causes eye lid to swell
 It’s due to restricted venous drainage
 Though swollen, eye lids are non tender
 No chemosis, extra ocular muscle movement
limitations and visual impairment

5. Group II – Orbital Cellulitis
 Pronounced oedema and inflammation of
orbital contents without abscess formation
 It is imperative to look for signs of proptosis
and reduced ocular mobility as these are
reliable signs of orbital cellulitis
 Chemosis is usually present in this group
 Loss of vision is very rare in this group, but
vision should be constantly monitored

6. Group III - Subperiosteal abscess
 Abscess develops in the space between the bone and
periosteum
 Orbital contents may be displaced in an inferolateral
direction due to the mass effect of accumulating pus
 Chemosis and proptosis are usually present
 Decreased ocular mobility and loss of vision is rare
in this group

7. Group IV - Orbital Abscess
 Orbital abscess usually involves collection of
purulent material within the orbital contents
 This could be caused due to relentless
progression of orbital cellulitis or rupture of
orbital abscess
 Severe proptosis, complete ophthalmoplegia, and
loss of vision are commonly seen in this group of
patients

8. Group V - Cavernous sinus thrombosis
 Development of bilateral ocular signs is the
classic feature of patients belonging to this
group
 Manifest with fever, headache, photophobia,
proptosis, ophthalmoplegia and loss of vision
 Cranial nerve palsies involving III, IV, V1, V2
and VI are common

9. ORBITAL SEPTUM The orbit is separated from the
soft tissue of the eyelid by the
orbital septum.
This is a fascial plane that is
continuous with the periosteum
of the facial bones.
Orbital septum inserts into the
tarsal plate of the upper and
lower eyelids.
It proves to be an effective
barrier that prevents the spread
of infection from the eyelids
posteriorly to the orbit.
While preseptal cellulitis can
spread to the orbital contents, it

10. ETIOLOGY
• Extension from neighbouring structures : Parasnasal sinuses, Teeth,
Face, Lids, Intracranial cavity, Intraorbital structures
This is the commonest mode of infection
• Exogenous Infection : Foreign body, Penetrating injury, Evisceration,
Enucleation, Dacryocystectomy, Orbitotomy
• Endogenous infection : Puerperal sepsis, Thrombophlebitis of leg,
Septicemia, rarely as metastasis from Ca Breast
• Predisposing factors like Diabetes mellitus and Immunocompromised
state also increases risk of infection.

11. AGENTS
BACTERIA
•Childrens- Staph aureus, Strep pneumoniae and anaerobics
•Adults- Staph aureus, Strep pneumoniae, E.coli,mixed flora
FUNGUS
•Diabetics and Immunocompromised
•Aspergillus, Mucor species
PARASITE
•Ecchinococcus Granulosus
•Taenia solium
•Trichinella spiralis
•Toxoplasma gondii

12. PATHOLOGY
FACTORS
Absent
Lymphatics
Thrombophlebitis
and Extensive
necrosis
Tight
Compartments

13. Pathological features of orbital cellulitis are similar to suppurative
inflammations of the body in general, except that
 Due to the absence of a lymphatic system the protective agents
are limited to local phagocytic elements provided by the orbital
reticular tissue
 Due to tight compartments, the intraorbital pressure is raised
which augments the virulence of infection causing early and
extensive necrotic sloughing of the tissues
 As in most cases the infection spreads as thrombophlebitis from
the surrounding structures, a rapid spread with extensiv
enecrosis is the rule

14. PATHOPHYSIOLO
GY
Oedema
Orbital infection in
connective tissue
Microflora
Invade and
proliferate in the
oedematous mucosa
Consolidation
forms abscess or
spread intracranially

15. SYMPTOM
S

16.  Fever, generally 102 degree F or greater
 Painful swelling of upper and lower lids
 Eyelid appears shiny and is red or purple in color
 Infant or child is acutely ill or toxic
 Eye pain especially with movement
 Decreased vision
 Eye bulging
 Swelling of the eyelids
 General malaise
 Restricted or painful eye movements

17. SIGNS
SIGNS
Lid Oedema
Chemosis
Proptosis
Restricted
Ocular
motility
Visual
impairment
Raised IOP

18.  A marked swelling of the lids characterised by woody
hardness and redness
 A marked chemosis of conjunctiva, which may
protrude and become desiccated or necrotic
 The eyeball is proptosed axially
 Frequently, there is mild to severe restriction of the
ocular movements
 Fundus examination may show congestion of retinal
veins and signs of papillitis or papilloedem

19. INVESTIGATIO
NS
INVESTIGATIONS
Complete
Haemogram
Bacterial Cultures
Nasal Swabs
Lumbar Puncture
X-Ray PNS
Ultrasound
CT Scan
MRI

20. ULTRASOUND
Rule out orbital
myositis
Determine foreign
bodies and abscess
Follow up of patients
of drained abscess

22. CTSCAN
Axial and coronal views
Extent of sinus disease
estimated
Features of osteomyelitis
Blurring of osseous margins
Extra or intra conal mass in
orbital cellulitis
Intraconal- Proptosis and soft
tissue shadow obliterated
Patchy enhancement of
intraconal fat in orbital
cellulitis
Thickened Optic nerve

23. AXIAL VIEW CT scan of the orbit with contrast
 There is Proptosis and Retrobulbar fat stranding.
 Note the mucosal thickening and fluid in the
ipsilateral ethmoidal (single asterisk) and sphenoidal
sinuses (double asterisk) consistent with acute

24. Coronal CT scan in a pediatric patient
with sinusitis as well as an orbital and
subperiosteal abscess (Left Side)

25. Coronal CT scan in a pediatric patient
with sinusitis and orbital abscess.

26. MRI
With Gadolinium contrast
enhancement
Orbital cellulitis - Smearing or linear
streaking of normal fat shadows on
normal T2 weighted images
Superior to CT in cases of Cavernous
sinus thrombosis
Help in planning of surgery and
evaluation of therapy

27. Orbital cellulitis and abscess

28. DIFFERENTIAL
DIAGNOSIS
Cavernous sinus thrombosis
Endocrine dysfunction
Orbital myositis
Orbital pseudotumor
Wegener granulomatosis

29. Cavernous Sinus Thrombosis
 Presents almost same symptoms and signs as in orbital
cellulitis, but with systemic features fever, headache
and an altered sensorium
 Thrombosis of the cavernous sinus is accompanied by
rigors, vomiting and severe cerebral symptoms
 Transference of symptoms to the fellow eye, which
occurs in 50% of cases
 Bilateral orbital cellulitis is very rare
 First sign is often paralysis of the opposite lateral
rectus

30. Thyroid associated ophthmopathy(TAO) or Grave’s
orbitopathy
 Symptoms are gritty sensations, photophobia, lacrimation,
discomfort,dysfunctional eye motility or diminution of vision
 Lid retraction
 Lid lag of the upper eyelid on downward gaze
 Axial proptosis (most common cause)
 Exposure keratitis
 Compressive optic neuropathy

31. 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 infiltration
of heterogeneous Consistency
 CT scan shows diffuse thickening of the extraocular
muscles including their tendinous insertion, which is
useful in differentiating this from thyroid eye disease
where the muscle enlargement is confined to the
belly and spares the terminal tendinous portion

32. Orbital Myositis
 It’s an inflammatory process that primarily involves the
extraocular muscles.
 The classic appearance of EOM myositis includes a unilateral
thickening of one or two EOMs, often also involving the
surrounding fat, tendon, and myotendinous junction
 Presents as orbital and periorbital pain, ocular movement
impairment, diplopia, proptosis, swollen eyelids, and
conjunctival hyperemia
 Orbital cellulitis, which is commonly accompanied by fever,
leukocytosis, and a clinical history of head and neck
infection

33. Wegener’s granulomatosis
 It’s a chronic disease affecting the upper respiratory tract,
lungs and kidneys and characterized bywide spread
distribution of necrotizing angiitis with surrounding
granuloma formation
 Symptoms include pain in the paranasal sinuses,
discoloured or bloody nasal discharge and, occasionally,
nasal ulcerations
 Persistent rhinorrhea
 Ocular manifestations occur secondary to an adjacent
granulomatous sinusitis or as a result of focal vasculitis
 The nasolacrimal duct may be obstructed and there may
be episcleritis, scleritis, proptosis and extraocular muscle

34. TREATMEN
T Intensive
Antibiotic
therapy
Analgesics
Anti
inflammatory
Surgical
Interventation

35. IV Antibiotics, anti biotic therapy should be continued
until patient is apyrexic for 4 days
Antifungals
Nasal decongestants
Diuretics to reduce the IOP
Lumbar puncture is done in meningeal or lumbar signs
develop and It is useful to do the swinging light test to
check for a Marcus Gunn pupil, which would indicate
optic nerve damage
Frequent ophthalmic assessment is mandatory in case of
intra cranial abscess formation, neurosurgical drainage
may be necessary

36. INDICATIONS OF SURGICAL
INTERVENTATIONS
Surgical
Interventio
n
Suspicion of
orbital
abscess or
foreign body
Progression
of visual loss
Extraocular
motility
defect
Worsening
of proptosis
Non
reduction of
size of
abscess on
CT after anti
biotic
therapy

37. TIMING OF SURGERY
Cellulitis
without
abscess with
VA < 6/12 with
appropriate
medical
treatment and
orbital
exploration
If VA > 6/12
expectantly
and frequently
conservative
management

38. SURGICAL
PROCEDURES
Free incision into abscess when pointing under skin or conjunctiva
Subperiostial abscess drained by 2-3 cm curved incision in upper
medial aspect
Draining of orbits and paranasal sinuses
Brain abscess- Craniotomy

39. COMPLICATIONS
Optic neuropathy
Cavernous sinus thrombosis
Orbital Apex Syndrome
Exposure keratitis
Orbital abscess
CRAO
Intraocular spread of infection
Septicemia
Pyaemia
Hearing loss

40. References
 Principles and Practice of Opthalmology- Albert &
Jakobiec
 Orbit, Eyelids, and Lacrimal System - AAO 2014-
2015
 Parson’s Diseases of the Eye – 22nd Edn
 Comprehensive Ophthalmology – Khurana
 Ophthalmology – Myron Yanoff and Jay S. Duker