Periorbital cellulitis begins anteriorly and causes a spreading infection in the upper and/or lower lids but does not penetrate through the orbital septum. There is usually an obvious external cause and patients usually will show no systemic signs. They have no significant fever, no leucocytosis, and symptoms are localized to the lids and conjunctiva. There is no pain on eye movement and vision is not impaired. Most importantly there is no evidence of sinusitis on plain film or CT.
Periorbital cellulitis may be caused by any of the following:
| 1. | SLIDE 1 shows a hyperacute bacterial conjunctivitis with swelling of the lids. |
| 2. | SLIDE 2 shows marked infection of the palpebral conjunctiva lining the in side surface of the lid, readily explaining the lid swelling. |
| 3. | SLIDE 3 shows a newborn with gonococcal conjunctivitis, characterized by massive purulent discharge and lid swelling. |
| 4. | On separating the lids marked injection of the bulbar conjunctiva is noted (as can be seen slide 4). This form of ophthalmia neonatorum is an ophthalmic emergency as the Neisseria organism is one of only two that can penetrate intact undamaged corneal epithelium, causing corneal perforation and loss of the eye (the other organism is Pseudomonas). |
| 5. | SLIDE 5 shows a child with multiple chalazia of both upper lids. Chalazia are caused by obstruction of the meibomian glands in the tarsal plate and characteristically the site of maximum swelling is removed from the lid margin. A hordeolum (stye) is caused by inflammation of the glands of Zeis or Moll located at the eye lid margin and are much less common than chalazia. In practical terms differentiation between these two is unimportant as the treatment is identical. |
| 6. | SLIDE 6 shows a large chalazia of the right lower lid with adjacent but localized cellulitis, but... |
| 7. | SLIDE 7 shows how
this inflammation can spread in the eye lid and cause a periorbital cellulitis.
Running your finger across the left upper lid will disclose an area of point
tenderness over the chalazion.
A chalazion or a hordeolum is treated with hot compresses, 10 minutes four times per day, and topical antibiotic drops such as Polysporin, Polytrim or 10% Sulpha. Of these two treatment modalities, hot compresses are far and away the most important as the disease process is encysted and is difficult for the topical medication to gain access to the site of infection. Styes generally will resolve with hot compresses, but chalazia, even though they are treated aggressively in the acute stage, may form a chronic granuloma, particularly in adults, which needs to be excised surgically. This is not done in the acute phase as most of these will resolve spontaneously. |
| 8. | SLIDE 8 shows a localized redness and induration of the eye lids, caused in this case by an epinephrine compound used in the treatment of glaucoma. |
| 9. | SLIDE 9 shows acute lid edema secondary to a black fly bite. The lid feels soft and doughy and is non-tender. |
| 10. | These resolve spontaneously (see slide 10) in a few hours following treatment with ice or cold compresses. Systemic antihistamines are not necessary. The acute lid swelling may be caused by an external bite, or more commonly a black fly enters the eye and lodges in the upper or lower fornix. |
| 11. | SLIDE 11 shows chicken pox with secondary infection. Note that the eye itself is completely white. |
| 12. | SLIDE 12 shows a primary herpes blepharoconjunctivitis which has become secondarily infected. These are treated with antiviral and topical antibiotics, but these children should be seen by an ophthalmologist to rule out corneal involvement. |
| 13. | Animal bites (SLIDE 13) often become secondarily infected causing periorbital cellulitis. The majority of these infections are caused by Pasteurella multocida and are treated with oral Penicillin or intravenous Cefazolin. |
| 14. | Congenital nasolacrimal duct obstruction (SLIDE 14) may show purulent discharge and tearing, but... |
| 15. | rarely causes a periorbital cellulitis (SLIDE 15). |
| 16. | Dacryocystitis or inflammation of the nasolacrimal sac itself is more common in adults and presents with point tenderness over the nasolacrimal sac (SLIDE 16) and secondary spreading cellulitis of the lower more than the upper lid. Systemic antibiotics are often indicated in the acute phase, following which an attempt should be made by an ophthalmologist to restore the patency of the nasolacrimal excretory apparatus. |
| 17. | Treatment is directed at the local condition. Systemic antibiotics may be indicated for more severe infections (SLIDE 17), particularly if there are systemic signs of toxicity. |