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Orbital cellulitis


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orbital cellulitis

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Orbital cellulitis

  1. 1. ORBITAL CELLULITIS Presented By Dr. Ankush D
  2. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 12. PATHOLOGY FACTORS Absent Lymphatics Thrombophlebitis and Extensive necrosis Tight Compartments
  13. 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. 14. PATHOPHYSIOLO GY Oedema Orbital infection in connective tissue Microflora Invade and proliferate in the oedematous mucosa Consolidation forms abscess or spread intracranially
  15. 15. SYMPTOM S
  16. 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. 17. SIGNS SIGNS Lid Oedema Chemosis Proptosis Restricted Ocular motility Visual impairment Raised IOP
  18. 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. 19. INVESTIGATIO NS INVESTIGATIONS Complete Haemogram Bacterial Cultures Nasal Swabs Lumbar Puncture X-Ray PNS Ultrasound CT Scan MRI
  20. 20. ULTRASOUND Rule out orbital myositis Determine foreign bodies and abscess Follow up of patients of drained abscess
  21. 21. 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
  22. 22. 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
  23. 23. Coronal CT scan in a pediatric patient with sinusitis as well as an orbital and subperiosteal abscess (Left Side)
  24. 24. Coronal CT scan in a pediatric patient with sinusitis and orbital abscess.
  25. 25. 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
  26. 26. Orbital cellulitis and abscess
  27. 27. DIFFERENTIAL DIAGNOSIS Cavernous sinus thrombosis Endocrine dysfunction Orbital myositis Orbital pseudotumor Wegener granulomatosis
  28. 28. 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
  29. 29. 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
  30. 30. 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
  31. 31. 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
  32. 32. 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
  33. 33. TREATMEN T Intensive Antibiotic therapy Analgesics Anti inflammatory Surgical Interventation
  34. 34. 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
  35. 35. 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
  36. 36. 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
  37. 37. 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
  38. 38. COMPLICATIONS Optic neuropathy Cavernous sinus thrombosis Orbital Apex Syndrome Exposure keratitis Orbital abscess CRAO Intraocular spread of infection Septicemia Pyaemia Hearing loss
  39. 39. 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