Grand Rounds Conference
Eric Downing MD
University of Louisville
Department of Ophthalmology and Visual Sciences
Subjective
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CC/HPI: Six year old male presented with fever, malaise, and
progressive periorbital pain, proptosis, and decreased VA OD x
3 days
Presented to pediatrician's office 2 days prior to admission,
diagnosed with sinusitis and was given oral Augmentin
Symptoms progressed so mom took him to Floyd Memorial one
day prior, where he was admitted for orbital cellulitis and placed
on IV Ampicillin and Ceftriaxone.
Pt and his mother complained of continued worsening
symptoms despite IV antibiotics at time of exam
History
POH: none
PMH: Recurrent nose bleeds
Eye Meds: none
Meds: PO Clindamycin x 1 day,
IV Clindamycin and Ceftriaxone x 1 day
Objective
VA:
Pupils:
IOP:
EOM:
OD
20/100
6→4
22
3+ restriction
in all fields of gaze
OS
20/20
6→4, no APD
soft
full
Objective
Pen Light Exam OD:
E/L/L: Severe periorbital
edema with tight upper and
lower lids, proptosis, 2mm
lagophthalmos
C/S: chemosis
K: Clear, no staining
AC: Formed
I/L: WNL
PLE OS: WNL
CT w/o Contrast
Assessment
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6 year old male presented with fever, malaise,
proptosis and blurry vision OD. Exam with
only mildly increased IOP, but significant
proptosis, lid tensity, significantly decreased
EOM, ↓VA, and chemosis.
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Dx: Orbital Cellulitis with secondary
compartment syndrome
Plan
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Lateral canthotomy/cantholysis
Consult Infectious Disease → recommended
switch to Vancomycin and Zosyn
Consult ENT for possible sinus drainage
Re-evaluate IOP and motility in 4 hours and in
AM
Next morning…
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IOP 26
Worsening proptosis
VA decreased to 20/800
MRI T1
MRI T2
Surgery
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Right orbital abscess drainage with external
ethmoidectomy and penrose drain placement
Gram Stain: Gram positive cocci
Culture: MSSA
Post-op
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Received 9
additional days of
IV antibiotics
VA returned to
20/25 with
significant
improvement of
motility
Discharged on
PO Clindamycin
Post-Op week 2
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VA stable at 20/25
EOM full
Orbital Cellulitis
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Infection of the soft tissues of the
orbit posterior to the orbital
septum
Three etiologies
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Extension from periorbital
structures, most commonly from the
paranasal sinuses.
Direct inoculation from trauma or
surgery
Hematogenous spread from
bacteremia
Background
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Prior to antibiotics, orbital cellulitis had a mortality rate of 17%,
20% were blind
Mortality rate has decreased dramatically, but severe vision loss
still occurs in 11% of patients
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Corneal exposure, neurotrophic keratitis, intraocular tissue destruction,
secondary glaucoma, optic neuritis, CRAO, orbital compartment
syndrome
Orbital cellulitis due to S. aureus still presents a significant risk,
even in spite of antibiotic therapy
Complications
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Meningitis (2%)
Intracranial abscess
Cavernous sinus thrombosis—mortality rate of 50%
Chandler Criteria
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1. Preseptal
2. Diffuse edema w/o
discrete abscess
3. Subperiosteal abscess
4. Orbital abscess with
ophthalmoplegia and
VA impairment
5. Extension into the
cavernous sinus
Chandler Criteria
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1. Preseptal
2. Diffuse edema w/o
discrete abscess
3. Subperiosteal abscess
4. Orbital abscess with
ophthalmoplegia and
VA impairment
5. Extension into the
cavernous sinus
Chandler Criteria
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1. Preseptal
2. Diffuse edema w/o
discrete abscess
3. Subperiosteal abscess
4. Orbital abscess with
ophthalmoplegia and
VA impairment
5. Extension into the
cavernous sinus
Chandler Criteria
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1. Preseptal
2. Diffuse edema w/o
discrete abscess
3. Subperiosteal abscess
4. Orbital abscess with
ophthalmoplegia and
VA impairment
5. Extension into the
cavernous sinus
Chandler Criteria
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1. Preseptal
2. Diffuse edema w/o
discrete abscess
3. Subperiosteal abscess
4. Orbital abscess with
ophthalmoplegia and
VA impairment
5. Extension into the
cavernous sinus
Epidemiology
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Median age is 7-12 years of age
Incidence increases in winter due to increase in
sinusitis
Children: 2:1 male/female predominance
In adults, there is no gender difference, except S.
aureus which is 4:1 female/male
History & Exam
Fever, headache, malaise
 Blurry vision
 Recent history of sinusitis or upper
respiratory tract infection
 Recent trauma, surgery, or dental work
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Proptosis
 Ophthalmoplegia +/- pain
 Chemosis
 Decreased VA
 Elevated IOP (~22%)
 Resistance to retropulsion
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Work-up
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Lab studies:
CBC (WBC > 15K)
 Cultures: blood and/or any purulent material
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Imaging
CT with contrast
 MRI to define abscess and determine cavernous sinus
disease
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Lumbar puncture if CNS or meningeal symptoms
develop
Treatment
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Prompt hospitalization with IV antibiotics
Canthotomy/cantholysis if orbital compartment
syndrome is present
Surgical indications
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Decreased VA
rAPD
If proptosis or abscess progresses despite antibiotic therapy
for 48-72 hours
Fungal infections—debridement is often necessary,
sometimes with exenteration of orbital and/or sinus tissues
Follow up
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At least daily monitoring with VA testing until
significant improvement
May switch to oral antibiotics is patient is clearly
improving AND has been afebrile for at least 48
hours
IV therapy is often indicated for 1-2 weeks,
followed by 2-3 weeks of oral antibiotics
Research
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JAAPOS Vol 18:3, June 2014, Pages 271-277
Retrospective review of 101 cases
71% of patients with abscess >3.8mL needed surgical intervention,
only 12% if <3.8mL
mL = ∏ x 4/3 x H x L x W
Suggested Chandler modification
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Stage 1: Preseptal cellulitis with no evidence of postseptal involvment
Stage 2: Signs of postseptal inflammation, such as orbital fat
edema/stranding and/or scleral thickening
Stage 3: Phlegmon or subperiosteal abscess formation <3.8mL
Stage 4: Abscess or phlegmon collection >3.8mL
Stage 5: Extraorbital involvement
References
1.
2.
3.
BCSC: Pediatric Ophthalmology and Strabismus. Pp195-197
Bergin DJ, Wright JE. Orbital cellulitis. Br J Ophthalmol. Mar
1986;70(3)174-8
Hornblass A, Herschorn BJ, Stern K, et al. Orbital abscess. Surv
Ophthalmol. Nov-Dec 1984;29(3):169-78