Orbital cellulitis is an inflammatory condition affecting the tissues behind the orbital septum. It typically presents with eyelid swelling and redness, vision loss, and pain with eye movement. The most common causes are sinus infections or infections of nearby structures that spread. Prompt diagnosis and treatment with antibiotics and imaging such as CT are important to prevent complications like abscesses or intracranial infections. Surgical drainage may be needed for abscesses. With appropriate treatment, outcomes have improved but orbital cellulitis still poses risks if not addressed quickly.

1. Orbital Cellulitis
Dr R S Walpitagamage
Registrar in Ophthalmology
TH Kandy
Sri Lanka

2. Orbital cellulitis- Introduction
• “An ENT disease with an ophthalmic manifestation”
• Orbital cellulitis (OC) is an inflammatory process that
involves the tissues located posterior to the orbital septum
within the bony orbit, but the term generally is used to
describe infectious inflammation.
• It manifests with erythema and edema of the eyelids, vision
loss, fever, headache, proptosis, chemosis, and diplopia.
• OC usually originates from sinus infection, infection of the
eyelids or face, and even hematogenous spread from distant
locations.
• OC is an uncommon condition that can affect all age groups
but is more frequent in the pediatric population.

3. Orbital cellulitis- Introduction
• Morbidity and mortality associated with the condition
have declined with advances in diagnostic and
therapeutic options; however, OC can still lead to
serious sight- and life-threatening complications in the
modern antibiotics era.
• Therefore, prompt diagnosis and treatment remain
crucial.
• Antibiotic coverage, computed tomography imaging,
and surgical intervention when needed have benefitted
patients and changed the disease prognosis.
• This is a major review the worldwide characteristics of
OC, predisposing factors, current evaluation strategies,
and management of the disease.

4. Predisposing factors
• Orbital cellulitis is most commonly seen in the
pediatric adolescent age groups and young adults.
• The most common source of infection is the
paranasal sinuses – the ethmoids (43%-94.7% study
from Canada) followed by the maxillary and frontal
sinuses.
• The infection proceeds from the sinuses to the
orbit, assisted by specific anatomical characteristics
valveless veins of the orbit, and foramina of the
orbital bones.

5. Predisposing factors
• Patients may either progress from a preseptal cellulitis or more
commonly develop orbital cellulitis from one of the various
sources
• Bacteria may infect the preseptal and orbital tissues through one
of three ways.
1. Direct inoculation. Examples include insect bites or accidental
trauma. These types of infection are usually caused by
Streptococcus aureus or pyogenes
A study in Pakistan OC in 6-16y Trauma is more common than
sinusitis
In India , Injury is associated with 24% of cases.
2. Adjacent ocular adnexal infections such as acute episodes of
sinusitis, dacryocystitis, or hordeolum which may spread to the
preseptal and postseptal spaces
3. Infection can also spread through hematogenous routes from a
distant source of infection such as otitis media or pneumonia.

6. Epidemiology
• OC is not a common condition
• Incidence 1.6 per 100000 in paediatric population
and than 0.1 per 100000 in adults.
• Gender distribution is equal but in India and Nigeria
males are more commonly affected and can be
attributed to work accidents.
• Seasonal presentation of OC in late winter –early
spring has been observed in Western studies,
directly associated with the sinus and URTI.

7. Microbiology
• The causative organisms associated with OC are
difficult to identify because of the normal flora of
the area, previous antibiotic therapy and multiple
agents that are usually contribute.
• Blood cultures are rarely positive in patients with
OC.
• Cultures from nasal swabs, throat swabs and ocular
secretions are generally more effective.
• cultures of material recovered from orbital
abscesses and sinus aspirates are reliable.

8. • The majority of studies in developed countries find
Staphylococcus aureus and Streptococcus species
as the most causative organism.
• Recent studies in both developed and developing
countries show increased trend of MRSA as a
causative organism.
• Streptococcal infection is age related.
• Younger children – Streptococcus pneumoniae
• Older children – Group A Streptococcus,
• Streptococcus milleri, Streptococcus viridans,
Streptococcus anginosus,

9. • Other frequently associated microorganisms in various
studies over the world -Coagulase negative
Staphylococcus
• Klebsiella pneumoniae
• Aspergillus
• Moraxella catarrhalis
• H.infuenzae
• Fungal OC – Mucomycosis and Aspergillosis seen in
high risk patients
• Immunocompromised
• DM
• On chronic steroids
• On antibiotics

10. Classification

11. Jain and Rubin Classification
1. Preseptal cellulitis
2. Orbital Cellulitis with or without intracranial
complications
3. Orbital abscess with or without intracranial
complications
a. Intraorbital abscess , which may arise from collection
of purulent material in an OC
b. Subperiosteal abscess, which may lead to true
infection of orbital soft tissues.

12. Clinical manifestations
• Clinical signs and symptoms at presentation may
differ according to the age.
• OC presents with classical signs.
• Since it can potentially lead to severe visual and life
threatening complications and progress rapidly,
prompt diagnosis and treatment are essential.
• The prevalence of signs is similar in developing and
developed countries.

13. • OC begins with general signs and symptoms such as
• Severe eyelid redness and edema –(71.5%-100%)
• Ptosis – (10.6%-33.3%)
• Conjuctival chemosis – (32%-45.3%)
• Discharge – (16.7%)
• Erythema of periorbital tissue and periocular pain or pain
with eye movements – (39.2%-36%)
• Additionally constitutional sigs develop; such as, fever,
leukocytosis, headache, general malaise and loss of
appetite.

14. • As the infection progress, there are signs that can
help differentiate between more superficial
infections and OC, such as
• Proptosis and globe displacement – (46.9-100%)
• Decreased vision – (12.5-37%)
• Afferent pupillary defect – (5.5-16.7%)
• Impaired color vision – (16.7%)
• Limited ocular motility – (39.1-84.6%)

16. Complications
• Ocular complications
• Subperiosteal abscess
• Orbital abscess
• Endophthalmitis/Panophthalmitis
• Optic neuropathy
• CRVO
• Intracranial complications
• Meningitis
• Cerebral abscess
• Cavernous sinus thrombosis

17. Differential diagnosis
• Various conditions can mimic OC, with the
characteristics of proptosis, chemosis, periorbital
swelling.
• In order to ascertain the correct diagnosis , a
thorough history , physical examination, laboratory
and imaging information are indispensable.
• DDs are quite extensive
• A primary neoplasm
• Rhabdomyosarcoma
• Malignent melanoma
• Leukaemia, lymphoma

18. • Metatstatic neoplasms
• Oesophagial adenocarcinoma
• Urothelial carcinoma
• Neuroblastoma
• Rhaumatological diseases
• Poliarteritis nodosa
• GCA
• Grnulomatosis with angitis
• Other rare conditions
• Spontaneous carotid cavanus fistula
• Haemorrhagic cysts
• Idiopathic orbital inflammatory disease
• Thyroid eye disease

19. Imaging
Computed tomography (CT)
• Computed tomography (CT) scan is the imaging
modality of choice in the diagnosis and monitoring of
patients with OC.
• Cases with periorbital inflammation, severe lid
oedema, proptosis, ophthalmoplegia and
deterioration of visual acuity or colour vision are
indications for CECT.
• Additional indication include
• Presence of CNS symptoms and signs,
• No improvement or deterioration of the patients condition
within 24hrs
• Non resolving pyrexia over 36hrs

20. Computed tomography (CT)
• CT provides imaging data of the anatomic elements
of the orbit, such as the orbital walls, EOM, optic
nerve, adipose tissue and paranasal sinuses.
• Therefore orbital infections and lesions can be
recognized.
• Additionally CT provides information on the
extension of the inflammatory changes in the
orbital structures, identification of potential
sources of the infection such as sinus disease, and
the presence of a foreign body.

21. Computed tomography (CT)
• CT scanning provides evidence for the identification
of an orbital abscess and defines its size and
location.
• The recognition subperiosteal abscess is more
accurate with the use of CT than clinically.
• To exclude cerebral abscess.
• A larger abscess appears as a fluid collection with
enhancement of rim. Contrast media may be used
for the differentiation between an abscess and
inflammatory process.

22. Magnetic resonance imaging (MRI)
• MRI is also a useful tool in identification of OC ,
especially when CT findings are unclear.
• MRI provides superior resolution than CT.
• Fat saturated T2 weighted MRI and diffusion weighted
imaging MRI is preferred.
• This is sensitive in differentiating OC from orbital
inflammatory disease and lymphoid lesions which
provide similar images.
• Sub periosteal and orbital abscesses and intracranial
involvement are also better identified with MRI than
CT.

23. Magnetic resonance imaging (MRI)
• Finally follow-up is safer with MRI as it does not
expose the patient to radiation.
• Increase scanning time compared to CT and
decrease availability of MRI are the disadvantages.

24. Management
Ophthalmic
and systemic
examination
Admission when suspected
Chandler 2,3,4.5
Image If
CT/MRI
Surgical Management
No abscess
Subperiostesl/Orbital
abscess,
Intracranial complication
Medical Management
Clinical improvement
Continue with medical management
No improvement or deterioration

25. Medical management
Empirical IV antibiotics
• Third generation
cephalosporin and
flucloxacillin
• Vancomycin if MRSA
suspected
• When culture and
sensitivity available
change accordingly
• Systemic steroid
• Nasal hygine
Laboratory check
• FBC
• Culture and sensitivity
• ESR
• CRP
• FBS
• BU/S.Createnine

26. Medical management
• Monitor temperature (QHT)
• Control blood glucose
• Systemic examination 4hrly
• Ophthalmic examination 12hrly
• If suspect complications frequent monitoring.
• If clinical improvement- continue IV antibiotics 1-2
weeks followed by oral 2weeks.

27. Surgical management
• Orbital or subperiosteal abscess often require prompt
drainage.
• Delayed drainage is likely to lead to serious
complications and poor visual outcome.
• There are different techniques for surgical removal of
subperiosteal or orbital abscesses.
• The traditional external method for medial abscess is
performed through Lynch incision, which offers
adequate visibility and effective drainage but leaves a
visible scar.
• Transnasal endoscopic surgery represents a great
advantage.

28. • In cases with Intracranial complications, surgical
treatment is indicated and should be planned
promptly after diagnosis.
• Delay in surgical drainage and decompression of
brain abscess is related to high morbidity and
mortality.
• Multidisciplinary approach is indispensable for
proper management in these situations, Including
Ophthalmologist, Oculoplastic surgeon, ENT and
Neurosurgeon and Paediatric/Medical team and
Microbiologist.

29. Thank you!