A 51-year-old woman with a past medical history of diabetes presented with two days of progressive eye swelling, discharge, and pain.
Here is what you see on examination. What diagnosis are you concerned about, and how would you treat this condition?
Orbital cellulitis is a vision-threatening condition in which infection occurs behind the orbital septum. This is different from preorbital cellulitis, a less virulent condition, which occurs anterior to the orbital septum. (J Fr Ophtalmol 2012;35:52.) Occurring most commonly in men and school-aged children (Oral Maxillofac Surg Clin North Am 2012;24:487), orbital cellulitis is a serious condition that results in vision loss in as many as 11 percent of those affected.
The etiology of orbital cellulitis is somewhat diverse, and includes extension from sinusitis (occurs in approximately 90% of cases), dental infection, disruption from trauma (e.g., orbital fracture), recent paranasal or orbital surgery, vascular extension from bacteremia, or super infection from an ocular foreign body. Post-traumatic or past surgical infection typically occurs within days of the event (J Coll Physicians Surg Pak 2009;19:39), but foreign body-related infections can occur months after the event. The type of inciting pathogen depends on whether the patient is immunocompetent and the etiology of the infection.
Patients can present with a red painful eye, eye discharge or tearing, proptosis, ophthalmoplegia, blurred vision, diplopia, or headache. (J Laryngol Otol 2013;127:1148.) The diagnostic workup of patients with suspected orbital cellulitis includes CT of the orbit with and without contrast to confirm the diagnosis and rule out a foreign body. Blood cultures to identify a bacteremic source as the etiology may be warranted, as may culture of any drainage. Patients may present with the classic painful eye movement, and also have decreased periorbital skin sensation, afferent pupillary defect, and optic nerve abnormalities.
Treating orbital cellulitis includes broad-spectrum IV antibiotics to cover gram-positive, gram-negative, and anaerobic organisms. (Pediatr Rev 2010;31:242.) An otolaryngologist should be consulted for possible surgical drainage if the etiology is from sinusitis. Surgical drainage is also recommended for refractory cases or where an abscess is noted. (J Craniomaxillofac Surg 2009;37:132.) Topical erythromycin is recommended to prevent corneal infection and damage from significant proptosis. Canthotomy should be performed in cases of severe swelling where orbital compartment syndrome is suspected. Decongestive agents are a recommended adjunct if an occluded sinus is thought to be the nidus of infection.
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