Orbital Cellulitis

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Orbital cellulitis is an infection of the soft tissues of the orbit posterior to the orbital septum. It may be  a  continuum  of  preseptal  cellulitis,  which  is  an  infection  of  the  soft  tissue  of  the  eyelids  and periocular region anterior to the orbital septum. Orbital cellulitis may result from an extension of an  infection  from  the  paranasal  sinuses  or  other  periorbital  structures  such  as  the  face,  globe,  or  lacrimal sac, direct inoculation of the orbit from trauma or surgery or as a haematogenous spread from bacteremia. 

Clinical presentation 

  • Fever,  malaise,  and  a  history  of recent sinusitis or upper respiratory tract infection
  • Proptosis and ophthalmoplegia are the cardinal signs of orbital cellulitis
  • Conjunctival chemosis, dyschromatopsia, and relative  afferent pupillary defect 
  • Decreased vision
  • Elevated intraocular pressure
  • Pain on eye movement
  • Orbital pain and tenderness are present early
  • Swollen eyelids, chemosis, hyperemia of the conjunctiva, and resistance to retropulsion of the globe may be present
  • Purulent nasal discharge may be present
  • For very ill children, vision may be difficult to evaluate in very ill children with marked edema

Investigations

  • Visual acuity
  • Slit lamp bimicroscopy
  • Tonometry
  • Fundoscopy
  • Full Blood Count and ESR
  • Blood culture
  • Assessment of purulent nasal discharge or from the abscess (swab for Gram Stain)
  • CT Scan of the orbits and paranasal sinuses with Contrast
  • MRI  will  help  differentiating  it  with other  diseases  but  also  identifying the source or extension of the disease

Non-pharmacological Treatment 

  • Patients must be hospitalized
  • Adequate hydration
  • Lower the temperature
  • Daily evaluation and monitor the vital signs
  • Management  of  orbital  cellulitis  is  done  with  consultation  from  other  medical  team (Neurosurgical (if brain extension is seen), ENT (for involvement of sinuses), Paediatrician (for paediatric patients) and Physicians

Pharmacological Treatment 

The antibiotic will be tailored when the laboratory results are out. 

Adults, give:  

B: ampicillin + cloxacillin (FDC) (IV) 1g stat then 500mg 6hourly for 2weeks 

AND 

A: gentamicin (IV) 160mg 24hourly for 7days 

AND 

B: metronidazole (IV) 500mg 8hourly for 7days 

AND 

S: vancomycin (IV) 15–20 mg/kg 8–12hourly 

Children more than one-month old give: 

B: ampicillin + cloxacillin (FDC) (IV) 50 mg /kg 8hourly for 7–14days 

AND 

A: gentamicin (IV) 7.5mg/kg, 24hourly for 5 -7days 

AND 

B: metronidazole (IV) 7.5–15mg/kg 6hourly for 7–10days 

AND 

S: vancomycin (IV) 10mg/kg 6hourly for 7–10days

Note: Individual dose not to exceed 1g  Children less or equal to one-month old give: 

B: ampicillin + cloxacillin (FDC) (IV) 25–50mg/kg 8hourly for 7–14days 

AND 

A: gentamicin (IV) 5mg/kg 24hourly for 5–7days 

Steroidal anti–inflammatory medicines  To be given after 48 hours of antibiotic therapy. Give: 

A: prednisolone (PO) 1–2mg/kg 24hourly to be tapered slowly

AND 

Adults: 

A: ibuprofen (PO) 400–800mg 6–8hourly; not to exceed 3.2g 24hourly 

OR 

A: paracetamol (PO) 1g 4–6hourly to a maximum of 4 doses 24hourly, for  3days 

Children: 

A: ibuprofen (PO) 30–40mg/kg per day in 3–4doses 

OR 

A: paracetamol 10–14 mg/kg for 3days 

Note: Do not use ibuprofen in patients with bleeding disorders or peptic ulcers 

Surgical TreatmentSurgical drainage is only indicated when there is: 

  • A decrease in vision
  • Development of an afferent pupillary defect
  • Progression of Proptosis despite appropriate antibiotic therapy
  • The size of the abscess does not reduce on CT scan within 48–72hours after appropriate antibiotics have been administered
  • If brain abscesses develop and do not respond to antibiotic therapy, then craniotomy is indicated
  • Presence  of  a  drainable  fluid  collection  is  evident  on  CT  scan  in  patients  older  than 16years