Periocular Infections

118  Marlene L. Durand

SHORT VIEW SUMMARY

Definition Microbiology be grossly apparent but can be measured as
• Periocular infections include infections of the • Lid infections: Staphylococcus aureus, 2 mm or more difference in Hertel’s
eyelids, lacrimal system, and orbit. streptococci exophthalmometer measurements),
• Eyelid infections include preseptal cellulitis, • Canaliculitis: Actinomyces israelii, also ophthalmoplegia, and vision loss. Preseptal
infections of the meibomian glands of the lids staphylococci, streptococci cellulitis has none of these features—only lid
(hordeolum, stye), sterile inflammatory • Dacryocystitis: S. aureus, streptococci; also edema and erythema. Computed tomography
granulomatous nodule in the lid (chalazion), gram-negative bacilli (CT) scan should be performed on any patient
and marginal blepharitis (inflammation at the • Orbital infections: S. aureus including with orbital findings. CT should be considered
lid margins). methicillin-resistant S. aureus, Streptococcus in children who present with what appears to
• Lacrimal system infections include anginosus (milleri), other streptococci be severe preseptal cellulitis because they may
dacryoadenitis (infection of the lacrimal (including Streptococcus pneumoniae), have subperiosteal abscess (see text).
gland), canaliculitis (infection of the gram-negative bacilli, anaerobes. Mixed
Therapy
canaliculi that collect tears in the medial infections common.
• Varies by diagnosis; see text.
canthus and drain into the lacrimal sac),
Diagnosis • Orbital infections are much more serious than
and dacryocystitis (infection of the lacrimal
• Clinical examination in lid infections, lacrimal preseptal cellulitis, and all orbital infections
sac).
system infections, supported by culture. must be treated with intravenous antibiotics.
• Orbital infections include orbital cellulitis,
• Preseptal cellulitis must be distinguished from Subperiosteal abscesses usually require
subperiosteal abscess, orbital abscess, and
orbital infections (orbital cellulitis, surgical drainage, and orbital abscesses almost
cavernous sinus thrombophlebitis. Acute
subperiosteal and orbital abscess). Orbital always do. Drainage of an adjacent infected
sinusitis is the most common cause of orbital
infections usually have one or more of the sinus may be indicated.
infections.
following findings: proptosis (which may not

Periocular infections include infections of the eyelids, lacrimal system, Chalazion

and orbital soft tissues that surround the globe of the eye. These infec- A chalazion is a sterile granulomatous reaction to inspissated sebum
tions may affect vision if not recognized and treated appropriately. within an obstructed meibomian gland. It may result from an internal
hordeolum or arise de novo.3 Patients present with a nontender nodule
EYELID INFECTIONS within the lid that points to the conjunctival surface. Chalazia may
Anatomy become large and press on the ocular surface, distorting vision. Most
Each eyelid contains a fibrous tarsal plate, which gives the lid its firm- chalazia resolve within 1 month, but recurrences are common in
ness (Fig. 118-1). Within each tarsal plate are 20 to 25 meibomian patients with chronic blepharitis. A randomized prospective trial treat-
(or tarsal) glands (Fig. 118-2). These glands may be seen as faint ing patients with primary chalazia that had persisted for at least 1
yellow lines on the inner surface of the everted lid, extending perpen- month despite conservative measures found that intralesional triam-
dicular to the lid margin. Meibomian glands are sebaceous glands that cinolone injection was as effective as incision and curettage.4 Persistent
secrete sebum, an oily substance. Sebum prevents the tear film from or recurrent chalazia should be biopsied to exclude sebaceous cell
evaporating too quickly from the ocular surface. At the lid margin, carcinoma of the lid.
adjacent to the eyelash follicles, are smaller sebaceous glands called
glands of Zeis. Marginal Blepharitis
Marginal blepharitis (Fig. 118-3) is a diffuse inflammation of the lid
Hordeolum margins. It is one of the most common conditions seen by ophthalmolo-
A hordeolum is an acute infection of a sebaceous gland of the lid, gists.5 Marginal blepharitis is usually due to an abnormality of meibo-
usually caused by Staphylococcus aureus. An internal hordeolum is an mian gland secretion, although superinfection with S. aureus may occur.
infection of a meibomian gland, and patients present with lid swelling, It may be mild, with redness and scaling at the margins (seborrheic
erythema, and tenderness. Internal hordeola may point toward either blepharitis), or more severe, with small marginal ulcerations and
the skin or the conjunctival surface. An external hordeolum (stye) is destruction of the hair follicles (ulcerative blepharitis). It is usually
an infection of a gland of Zeis, and patients present with a painful chronic and remitting, and it is often associated with seborrheic derma-
pustule, which points to the lid margin. Internal and external hordeola titis or rosacea. Treatment of the chronic condition is with gentle eyelid
usually respond to frequent warm compresses. Topical bacitracin or scrubs (e.g., twice daily with baby shampoo), with the addition of baci-
erythromycin ointment may be used at night. Incision and drainage of tracin ointment to the lid margins for acute inflammation. Oral tetracy-
the lesion is rarely required. There have been no randomized studies cline may be helpful if there is associated rosacea. Malassezia yeasts have
of the various medical treatments commonly prescribed for acute been associated with seborrheic dermatitis.6 Seborrheic dermatitis may
internal hordeola (e.g., warm compresses, antibiotics, lid scrubs), so respond to antifungal agents, such as a short course of itraconazole.7
the effectiveness of various treatments is unknown.1 Methicillin- Case reports of rare causes of blepharitis or blepharoconjunctivitis
resistant S. aureus (MRSA) may play a role in some cases.2 have been published. Pseudomonas aeruginosa caused an acute
1432
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 1432.e1
KEYWORDS
blepharitis; cavernous sinus thrombophlebitis; dacryocystitis; orbital
abscess; orbital apex syndrome; orbital cellulitis; subperiosteal

Chapter 118  Periocular Infections

abscess

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 1433

Periosteum

Chapter 118  Periocular Infections

Orbital septum

Tarsal plate

Meibomian gland

Gland of Zeis

FIGURE 118-4  Blastomycosis involving the eyelid in an otherwise

healthy man with a normal chest radiograph. (Courtesy Dr. John
Bennett.)

necrotizing blepharoconjunctivitis and subsequent facial cellulitis in a

FIGURE 118-1  Diagram of the anterior portion of the eye and patient with chemotherapy-induced leukopenia.8 Leishmania donovani
orbit, illustrating the orbital septum and tarsal plate of the eyelid. caused blepharoconjunctivitis in a patient with post-kala-azar dermal
Infections anterior to the orbital septum are described as preseptal, leishmaniasis.9 Capnocytophaga ochracea caused a chronic blepharo-
whereas infections posterior to the septum are considered orbital. Meibo- conjunctivitis in a 70-year-old immunocompetent patient; the organ-
mian glands lie within the tarsal plate. ism was also isolated from the gingiva.10 Phthiriasis palpebrarum is
infestation of the eyelashes by crab lice. Patients have pruritus of the
lid margins and blepharoconjunctivitis.11 Herpes simplex blepharitis
Superior has been described in adults and children, may be recurrent, and is
tarsus occasionally bilateral.12,13 Blastomycosis is a rare cause of a granuloma-
tous blepharitis (Fig. 118-4). Demodex mites are common ectoparasites
Superior of the skin and may infest the lid margins; infestation is associated with
tarsal cylindrical dandruff around the lashes. Demodex folliculorum can be
glands found in the lash follicle and D. brevis in sebaceous and meibomian
Excretory glands.14 There has been recent interest in the potential association
Lateral
ducts between Demodex and chronic blepharitis, an association that was first
canthus Medial postulated 50 years ago.15 Studies of topical treatments have found that
canthus lid scrubs with tea tree oil (from the leaf of the tree Melaleuca alterni­
folia) are effective in eradicating Demodex,16 and such scrubs have
Posterior effectively treated some cases of chronic blepharitis.14 A case of chronic
rims of lids blepharitis that mimicked sebaceous gland carcinoma was found to be
Inferior tarsal
due to Demodex on lid biopsy and responded to tea tree oil lid scrubs.17
Inferior gland
tarsus INFECTIONS OF THE LACRIMAL
FIGURE 118-2  The meibomian glands. (From Warwick RE. Wolff’s SYSTEM
Anatomy of the Eye and Orbit. Philadelphia: Saunders; 1976.) Anatomy
The lacrimal gland is located beneath the upper outer orbital rim (Fig.
118-5). It produces tears that flow across the eye and then drain
through the puncta, canaliculi, lacrimal sac, and lacrimal duct into the
nasal cavity. The only parts of the lacrimal system that are visible on
examination are the puncta and sometimes the lacrimal gland. The size
of the lacrimal gland varies, but a portion may be visible in some
patients when the upper lid is everted and the patient looks down and
in. The gland then appears as a pink mass under the conjunctiva, just
under the lateral part of the upper orbital rim.

Dacryoadenitis
Dacryoadenitis is an inflammation of the lacrimal gland. Infections are
rare and may be acute or chronic. Patients with acute dacryoadenitis
present with a tender area of erythema and swelling in the lateral part
of the upper lid. It may lead to preseptal or orbital cellulitis or may
suppurate into an abscess.18,19 S. aureus is the most common pathogen,
although streptococci may also be a cause.20 A recent series of 11 cases
of acute bacterial dacryoadenitis with positive cultures from lid aspi-
rate, biopsy, or purulent drainage reported S. aureus in over half
FIGURE 118-3  Photograph of eyelids with marginal blepharitis. (6 cases), followed by Streptococcus pneumoniae (2), mixed skin flora

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 1434
Lacrimal gland Puncta of the canaliculus. Occasionally, surgical exploration is required. Anti-
biotics given topically as eyedrops (ciprofloxacin plus cefazolin) several
times daily, with or without irrigation of the canaliculi with antibiotics,
was effective in all patients in one series from India.48
Part II  Major Clinical Syndromes

Dacryocystitis
Lacrimal sac Dacryocystitis, or inflammation of the lacrimal sac, is the most
common infection of the lacrimal system. It arises because of obstruc-
Canaliculum tion of the lacrimal duct, pooling of tears in the lacrimal sac, and
Lacrimal duct subsequent infection. Obstruction may be congenital or may result
(lies in bone)
from trauma, tumors, infection, or inflammation of the duct. Acute
dacryocystitis symptoms include pain, swelling, and erythema near the
nasal corner of the eye. There is usually epiphora (excessive tearing)
and a purulent discharge. Infants often have lacrimal duct obstruction
with epiphora, but acute dacryocystitis complicates the obstruction in
only 3%.49 The most common causes of acute dacryocystitis are S.
aureus and streptococci. Gram-negative bacilli accounted for 25% of
Inferior nasal isolates in one study, with Escherichia coli as the most frequent gram-
turbinate negative organism isolated.50 Treatment requires antibiotic therapy
FIGURE 118-5  The lacrimal system. (Modified from Barza M, Baum (e.g., ampicillin-sulbactam) and usually incision and drainage of a
J. Ocular infections. Med Clin North Am. 1983;67:131-152.) lacrimal sac abscess. In one study, incision and drainage was an out-
patient procedure requiring only local anesthesia in approximately
80% of cases.51 A repeat drainage procedure was required within 1
(2), and Haemophilus influenzae (1).21 There are case reports of acute month in 8%. Chronic or recurrent dacryocystitis usually requires a
suppurative dacryoadenitis due to Pseudomonas, brucellosis, and surgical procedure, dacryocystorhinostomy (DCR). One study found
cysticercosis.22-24 Epstein-Barr virus may cause acute nonsuppurative that cultures taken at the time of DCR surgery were positive in nearly
dacryoadenitis in mononucleosis, which may be unilateral or bilat- half of the 114 patients studied, although only one fifth of the patients
eral.25,26 It may result in keratoconjunctivitis sicca.27 Acute herpes had a history of dacryocystitis.52 Staphylococcus epidermidis and S.
zoster dacryocystitis was described in a patient who, 2 days later, devel- aureus were the only organisms isolated in 45% and 24% of culture-
oped iridocyclitis and shingles in the distribution of the first division positive cases. Whether these reflect nasal flora contamination is
of the trigeminal nerve.28 A study found that dacryoadenitis was unknown. Gram-negative bacilli composed a larger percentage of iso-
present in one third of patients with Acanthamoeba keratitis, although lates in patients with a history of dacryocystitis, a finding also noted
direct infection of the lacrimal gland was not found.29 Chronic infec- by others.53 Gram-negative bacilli were present in 26% of cultures in a
tious dacryoadenitis is rare, but most reports describe Mycobacterium recent study, with H. influenzae predominating.54 Anaerobes were
tuberculosis as the cause.30-32 Most cases of chronic dacryoadenitis are found in 19%. Fungi have been reported as a cause of two cases of
inflammatory rather than infectious, however. Sjögren’s disease and dacryocystitis, including one with mucormycosis involving the lacri-
sarcoidosis are the most common associated diseases, although cases mal sac.55 Rhinosporidium seeberi, an aquatic protistan parasite seen
of Crohn’s disease and Wegener’s disease presenting as chronic dacryo- especially in tropical climates such as southern India, may cause
adenitis have been described.33,34 Granulomatous inflammation of chronic dacryocystitis. A recent report from India described 50 patients
bilateral lacrimal glands was seen in one patient receiving interferon-α seen with ocular rhinosporidiosis over a 2.5-year period; half had
and ribavirin for hepatitis C; evaluation for sarcoidosis was negative.35 conjunctival involvement, and 26% had lacrimal sac involvement.56
Tumors cause approximately 25% of cases of chronic lacrimal gland Bloody discharge from the puncta was a feature of lacrimal sac infec-
enlargement.20 tion, and at surgery, a pink, vascularized growth was found in the
lacrimal sac.
Canaliculitis Patients with an episode of acute dacryocystitis who do not ulti-
Canaliculitis may occur spontaneously or develop after placement of mately undergo a DCR procedure may have further episodes of acute
silicone in the canaliculi (e.g., punctal plugs to treat dry eyes) or in the dacryocystitis. One study found that 4 of 16 patients with a lacrimal
nasolacrimal system (tubes for tear drainage). Infections have also abscess who did not eventually have a definitive procedure (DCR or
been associated with the more recent types of canalicular plugs made dacryocystectomy) developed a recurrent lacrimal sac abscess.51
from a temperature-sensitive acrylic polymer.36 Canaliculitis results in
chronic symptoms of tearing and irritation in the medial portion of PRESEPTAL CELLULITIS AND
the affected eyelid. Examination reveals a swollen, “pouting” punctum ORBITAL INFECTIONS
and erythema of the adjacent nasal conjunctiva. There may be a uni- Anatomy
lateral conjunctivitis. The lower canaliculus is affected more often than The orbital septum is a thin, fibrous membrane that serves as a barrier
the upper.20 A yellow-green exudate and yellowish concretions may be between the superficial lids and the orbit. The septum arises from the
expressed from the involved punctum in many cases of canaliculitis. orbital periosteum at the orbital rim and extends to the tarsal plates of
The concretions, called sulfur granules, are formed by Actinomyces the eyelids (see Fig. 118-1). Infections anterior to the septum are pre-
israelii, the organism in the majority of cases.37 A recent review of the septal, and infections posterior to the septum are orbital. Preseptal
literature found that of 188 reported cases, Actinomyces (30% of cases), cellulitis involves only the lids and not the orbit, whereas orbital cel­
streptococci (12%), and staphylococci (10%) were the most common lulitis involves the soft tissues (fat, muscle) contained within the bony
etiologies, while cultures were negative in 22%.38 In a series from India orbit (Fig. 118-6). The bony orbit is shaped like a cone placed horizon-
of 74 patients with primary canaliculitis, staphylococci were cultured tally, apex tilted medially. It is surrounded by the paranasal sinuses for
in 39% of cases.39 Mycobacterium chelonae has been the etiology in much of its circumference: the frontal sinus superiorly, the maxillary
several cases, usually associated with punctal plugs.40,41 Rare causes sinus inferiorly, and the ethmoid medially. The medial orbital wall, the
include Propionibacterium propionicum,42 Eikenella corrodens, either paper-thin lamina papyracea, is also the lateral wall of the ethmoid
alone43 or with Streptococcus anginosus (milleri) group,44 Arcanobacte­ sinus. It contains multiple foramina for nerves and blood vessels and
rium haemolyticum,45 Enterobacter cloacae,46 and Nocardia asteroides.47 natural defects called Zuckerkandl’s dehiscences. For these anatomic
Nocardia was found in canalicular cultures of 5 of 12 canaliculitis reasons, ethmoid sinusitis is the most common cause of sinus-related
patients in a series from Chennai, India.48 Treatment requires removal orbital infection. Periosteum (periorbita) lines the orbit, and infection
of canalicular material and concretions, usually accomplished by from the ethmoid sinus may cross the lamina papyracea and collect
applying pressure near the nasal corner of the eye or by office curettage beneath the periorbita as a subperiosteal abscess. Infection may break

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 1435
Preseptal cellulitis Orbital cellulitis The etiology of sinus-related preseptal and orbital cellulitis is usually
unknown because blood cultures are often negative. Sinus cultures in
these cases reveal typical acute sinusitis pathogens, such as S. pneu­
moniae and H. influenzae. Some studies show S. aureus as a major

Chapter 118  Periocular Infections

sinus pathogen.62
Subperiosteal abscess is caused by ethmoid sinusitis in nearly all
cases. Abscess cultures show S. pneumoniae, group A streptococcus,
nontypeable H. influenzae, and S. aureus as the major pathogens.63,64
Harris63 noted that bacteriology varies with age. Greater than 80% (10
of 12) of children younger than age 9 years in his study had negative
cultures or their infection cleared after intravenous antibiotics without
A drainage, and the culture-positive cases grew only single aerobes (S.
B aureus or S. pneumoniae). Infection in children age 9 years or older did
not usually clear on intravenous antibiotics alone, and drainage cul-
tures were positive for multiple organisms, usually a mixture of aerobes
Subperiosteal abscess
and anaerobes. Aerobes included S. anginosus (milleri) group, group A
and group C streptococci, S. aureus, H. influenzae, and Moraxella
catarrhalis, whereas anaerobes included Peptostreptococcus, Eikenella,
Fusobacterium, and Bacteroides spp. A recent study of children with
sinogenic orbital cellulitis or subperiosteal abscess evaluated the
C
changing bacteriology since the widespread use of the 7-valent pneu-
mococcal conjugate vaccine (PCV7) and found a marked decrease in
infections due to S. pneumoniae or viridans streptococci but an increase
in S. aureus infections, including MRSA.65 Brook and Frazier66 found
that subperiosteal abscesses in adults were also polymicrobial, with a
similar mixture of aerobes and anaerobes. These cultures agreed with
maxillary sinus puncture cultures obtained from the same patients. A
study of orbital cellulitis and abscess in children found that S. anginosus
(milleri) was the most common pathogen (44% of culture-positive
D Orbital abscess E Cavernous sinus thrombophlebitis cases), followed by S. aureus.67 A study of 53 patients, two-thirds adults,
FIGURE 118-6  Five diagrams illustrating preseptal cellulitis (A), orbital
with sinogenic orbital or subperiosteal abscess found that the major
cellulitis (B), subperiosteal abscess (C), orbital abscess (D), and cavernous pathogens were streptococci (37%), S. aureus (28%), gram-negative
sinus thrombophlebitis (E). (Modified from Chandler JR, Langenbrunner bacilli (17%), and anaerobes (19%).68 Methicillin-resistant S. aureus
DJ, Stevens FR. The pathogenesis of orbital complications in acute sinusitis. accounted for 6.5% of cases; one third of cultures grew more than one
Laryngoscope. 1970;80:1414.) pathogen.
Preseptal cellulitis may have two other causes besides sinusitis:
bacterial superinfection of a rash or break in the eyelid skin, and bac-
through the periorbita or coalesce from an orbital cellulitis and form teremic seeding. The first may follow trauma, an insect bite, or herpetic
an orbital abscess. The venous drainage of the middle third of the lid lesions (herpes simplex or zoster). The pathogens are usually S.
face and paranasal sinuses is primarily through the valveless orbital aureus or group A streptococcus. Preseptal cellulitis that is part of a
veins, which drain inferiorly to the pterygoid plexus and posteriorly to facial cellulitis or erysipelas is included in this category. Rare cases of
the cavernous sinus.57 As a consequence, cavernous sinus thrombophle­ group A streptococcal preseptal cellulitis have been complicated by
bitis may occur as a complication of a sinus or orbital infection (see either streptococcal toxic shock syndrome or eyelid necrosis.69,70 P.
Chapter 93). aeruginosa also caused lid necrosis as a complication of blepharitis and
preseptal cellulitis in one case.71 Other unusual causes of preseptal cel-
Epidemiology lulitis include ringworm,72 atypical mycobacteria,73 and anthrax.74 The
Preseptal cellulitis is much more common than orbital cellulitis. In a second cause, bacteremic seeding of the lids, occurs in infants and
review of 315 pediatric patients (age 18 years or younger) with either young children (usually younger than 3 years). This syndrome has
infection treated in two adjacent Boston hospitals between 1980 and become much less common since the introduction of H. influenzae
1998, 94% were preseptal cellulitis cases.58 Both conditions occur most type b (Hib) vaccine in 1990. Before the Hib vaccine, preseptal cellulitis
often in young children: 75% of patients in the Boston study were was associated with bacteremia in 10% to 33% of cases, with 80% to
younger than 5 years. Children with orbital cellulitis tend to be slightly 100% of these cases due to H. influenzae.75-77 Large studies in the Hib
older than children with preseptal cellulitis. The average age of orbital vaccine era found only 4% to 8% of cases were bacteremic, with no
cellulitis patients in the Boston study was 5 years versus 3 years for cases due to H. influenzae type b bacteremia after 1987.59,78 Strepto-
preseptal cellulitis patients. A study from New York found similar cocci, especially S. pneumoniae and group A streptococcus, are the
results, with an average age of 7.6 years for orbital cellulitis and 4.6 main causes of bacteremia now,79 although nontypeable H. influenzae
years for preseptal cellulitis.59 Frequently the term orbital cellulitis is is still an occasional pathogen.58,59,78
used in the literature imprecisely to include cases of subperiosteal and Orbital cellulitis and orbital abscess are usually caused by sinusitis,
orbital abscess in addition to cellulitis. The distinction is important but rare cases follow penetrating trauma, orbital surgery, canalicular
clinically because abscesses usually require surgical drainage. Subperi- surgery, peribulbar anesthesia for eye surgery, endophthalmitis, dental
osteal abscess occurs almost as often as uncomplicated orbital cellulitis abscess, dacryocystitis, or dacryoadenitis.61,80-84 These nonsinusitis eti-
and accounts for 2% to 10% of all cases of preseptal and orbital infec- ologies may be more common in adults than children. In a study from
tions in large inclusive series.58-60 Orbital abscess is rare, accounting for Australia, 91% of children with orbital cellulitis or abscess had sinus-
less than 1% of cases in these series. itis, whereas only half of adults did.62 The remaining adults had dac-
ryocystitis, trauma, endophthalmitis, and secondarily infected nasal
Etiology and Bacteriology tumor as etiologies. There was no case of posterior extension of pre­
Sinusitis causes 80% to 90% of all cases of preseptal and orbital cellu- septal cellulitis in either children or adults in this study, and the inci-
litis.47 The ethmoid sinus is involved in most of these cases, followed dence of this is unknown.
by the maxillary sinus. The frontal sinus, which does not develop until An unusual cause of preseptal or orbital cellulitis is pneumococcal
at least age 6 years, is involved occasionally in older children and bacteremia. Cellulitis of the head and neck region from bacteremic
adults.61 Sphenoid sinusitis rarely leads to bacterial orbital infections. pneumococcal infection is well described in patients with lupus

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 1436
erythematosus or hematologic disorders.85 Patients with lupus who syndrome in immunocompromised or normal hosts and may have a
develop this may just have started corticosteroid therapy. Pneumococ- subacute presentation.91,92 Pseudallescheria boydii has been described
cal orbital cellulitis has also been described in a previously healthy as an etiology in rare cases of invasive fungal infection involving the
adult without bacteremia.86 Pseudomonas preseptal or orbital cellulitis orbital apex.93 Rare cases of orbital apex syndrome are due to
Part II  Major Clinical Syndromes

may occur in neutropenic cancer patients secondary to Pseudomonas bacteria.94-96 Visual loss is usually irreversible.
bacteremia.87,88 If the infection is localized immediately anterior to the orbital apex,
a “superior orbital fissure syndrome” may occur. This syndrome has the
Clinical Manifestations same cranial neuropathies as orbital apex syndrome except there is no
Preseptal and Orbital Cellulitis involvement of the optic nerve. If the infection is posterior to the orbital
Preseptal cellulitis must be distinguished from orbital cellulitis, a much apex, a “cavernous sinus syndrome” may occur. This has the same
more dangerous infection. The term periorbital cellulitis, sometimes cranial neuropathies as orbital apex syndrome except with the added
used for preseptal cellulitis, should be avoided because it does not involvement of the second division of cranial nerve V and sometimes
make this distinction clear. In preseptal and orbital cellulitis, the lids the oculosympathetic fibers. In addition, because the cavernous sinus
are red and swollen. The lids may be swollen shut, but it is essential to is a venous plexus that extends to the opposite side, bilateral cranial
examine the eye to evaluate visual acuity and extraocular movement. neuropathies are typical. The superior orbital fissure, orbital apex, and
In preseptal cellulitis, vision is normal, there is no afferent pupillary cavernous sinus are contiguous and the etiologies are similar.89 Infec-
defect, extraocular movements are full and painless, and there is no tions rarely respect the precise anatomic locations these syndromes
proptosis. In contrast, patients with orbital cellulitis have some degree imply, and infections may be in the cavernous sinus, for example,
of ophthalmoplegia or proptosis, or both. There is often deep eye pain without having all the features of the cavernous sinus syndrome. Infec-
and pain with eye movement. Proptosis may not be grossly apparent tious etiologies for all of these syndromes include fungi, bacteria such
and should be measured (e.g., with Hertel’s exophthalmometer); a dif- as S. aureus, streptococci including S. anginosus (milleri), gram-negative
ference of 2 mm or more is significant. Vision may be decreased, and bacilli, syphilis, and herpes zoster. Herpes zoster ophthalmicus (HZO)
an early warning sign may be an afferent pupillary defect. Fever and may rarely be complicated by complete unilateral ophthalmoplegia or
leukocytosis are usually present in children with preseptal or orbital orbital apex syndrome. In a review of 20 cases, HZO preceded ophthal-
cellulitis, but they may be absent in adults. Fever was present in 70% moplegia in 75% and occurred concurrently in 20%.97
of pediatric cases but only 30% of adult cases in one series.62
Cavernous Sinus Thrombophlebitis
Orbital and Subperiosteal Abscesses Septic cavernous sinus thrombophlebitis is rare and should be sus-
Patients with an orbital or subperiosteal abscess usually present with pected in any patient with orbital cellulitis who develops contralateral
marked lid swelling and erythema, eye pain, proptosis, marked oph- signs of orbital inflammation (lid swelling, proptosis, ophthalmople-
thalmoplegia, and often vision loss. Most have fever. Because the gia) (see also Chapter 93). Spread to the opposite eye occurs through
abscess is medial or superomedial in nearly all cases, the eye is typically the cavernous sinus and usually occurs within 24 to 48 hours of the
fixed looking “down and out” (Fig. 118-7). initial unilateral orbital findings.98 Patients may also present with bilat-
eral findings, including lid edema, chemosis, proptosis, ptosis, and
Orbital Apex, Superior Orbital Fissure, and ophthalmoplegia, or they may present with signs of bilateral neuropa-
Cavernous Sinus Syndromes thies of some or all of cranial nerves III, IV, and VI but without the lid
Orbital apex syndrome is characterized by marked ophthalmoplegia edema and erythema that typifies orbital cellulitis. The latter is espe-
and vision loss. The cranial nerves of the orbital apex are involved, cially true in cases of cavernous sinus thrombophlebitis that arise from
which include the optic nerve and cranial nerves III, IV, VI, and the skin infections of the mid third of the face, or in dental infections,
first division of V. There is often an afferent pupillary defect due to rather than primary orbital infections. In cavernous sinus thrombo-
involvement of the optic nerve and hypoesthesia of the forehead phlebitis, there may be decreased sensation over the forehead and
due to involvement of the first division of cranial nerve V. Etiologies sometimes cheek due to involvement of the first or second division of
include vascular (e.g., carotid cavernous fistula); inflammatory (e.g., cranial nerve V. Trigeminal nerve involvement may be seen in a quarter
giant cell arteritis, Wegener’s disease); neoplastic (e.g., lymphoma, of patients with cavernous sinus thrombophlebitis but is not a feature
head and neck cancers, neural tumors); and infectious.89 In infectious of usual bacterial orbital cellulitis.99 Early cases may present with uni-
orbital apex syndrome, unlike orbital cellulitis, marked vision loss lateral findings of orbital cellulitis and cavernous sinus syndrome but
and ophthalmoplegia may occur with minimal or no lid swelling or with persistent headache and lethargy. This was illustrated in a recent
erythema. Overt signs of orbital inflammation may worsen subse- case report of a child with cavernous sinus thrombophlebitis, sphenoid
quently. This syndrome is usually caused by infection in the adjacent sinusitis, and S. anginosus (milleri) bacteremia in whom the clues to
posterior ethmoid or sphenoid sinuses, and most cases are due to more serious infection were unrelenting headache, fever, and leth-
invasive mold infections. Orbital apex syndrome is a well-known pre- argy.100 Visual loss may occur from venous congestion and ischemia.
sentation of mucormycosis.90 Aspergillus may cause an orbital apex Patients are usually febrile and may be lethargic or obtunded. There is
often sphenoid and posterior ethmoid sinusitis. S. aureus is the major
pathogen, and cases of methicillin-resistant S. aureus have also been
described.101 Other pathogens include streptococci, especially S. angi­
nosus (milleri) group, anaerobes, and gram-negative bacilli.102-104 Two
cases with a subacute presentation involved Actinomyces in one
and Aggregatibacter (Actinobacillus) actinomycetemcomitans in the
other.105,106 In both cases, patients initially were misdiagnosed as having
Tolosa-Hunt syndrome, an idiopathic, steroid-responsive inflamma-
tory process involving the cavernous sinus.

Laboratory and Radiologic Studies

Laboratory studies (white blood cell count, blood cultures) should be
obtained in all patients with preseptal or orbital cellulitis. Leukocytosis
with a left shift is present in most patients. Blood cultures are rarely
positive in older children and adults but may be positive in up to 8%
of young children, as noted earlier.
The most helpful study in evaluating a patient with orbital infection
FIGURE 118-7  Patient with orbital abscess (eye looks “down and is computed tomography (CT). A CT scan should be performed in
out”). any patient with orbital signs (ophthalmoplegia, proptosis, decreased

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 1437
vision, or a combination of these) because it is essential to identify an of 8 patients with cavernous sinus thrombophlebitis and 30 control
abscess that may require urgent drainage. Repeat scans should also be patients, 2 independent radiologists blinded to the cases reviewed the
obtained in any patient with presumed uncomplicated orbital cellulitis CT images.112 They correctly diagnosed 7 of the 8 patients with cavern-
who fails to improve, or worsens, on intravenous antibiotics alone. A ous sinus thrombosis on initial CT images and correctly diagnosed the

Chapter 118  Periocular Infections

CT scan may not be necessary in many cases of preseptal cellulitis eighth on a repeat CT obtained 4 days after presentation. They also
because the diagnosis may be made clinically. However, several reports correctly read all of the control CTs as normal. Six of the 8 patients
highlight the fact that in children, orbital signs may be absent yet they with cavernous sinus thrombophlebitis also underwent MRI, but this
may have an orbital or subperiosteal abscess. Some authors advocate was not superior to fine-cut contrast-enhanced CT.
CT for all children with preseptal cellulitis, however, and report three The differential diagnosis of bacterial orbital cellulitis includes
cases of subperiosteal abscess that presented similar to preseptal cel- orbital pseudotumor, tumor, and invasive fungal disease (invasive
lulitis, with no proptosis, visual decrease, or ophthalmoplegia.107 A sinus aspergillosis and mucormycosis). Orbital pseudotumor is an
recent retrospective study that included 111 children (median age, 7) idiopathic disease, more common in adults than children, that often
with orbital or subperiosteal abscess on CT found that proptosis, oph- manifests with painful ophthalmoplegia. It may appear with inflamma-
thalmoplegia, and pain with eye movement were risk factors for tory proptosis, mimicking orbital cellulitis.113,114 Patients with tumors
abscess, but half lacked these findings.108 This study found that marked of the orbit may present with acute inflammation mimicking orbital
lid inflammation with edema extending beyond the lid margins, high cellulitis. This has been described in primary ophthalmic rhabdomyo-
white blood count (neutrophil count >10,000), and previous antibiotic sarcoma and retinoblastoma.115,116 Rhinocerebral mucormycosis, which
therapy were also risk factors for abscess. frequently manifests as an orbital cellulitis, is discussed in Chapter 260.
If performed, CT in preseptal cellulitis shows lid edema but no Mucormycosis should be considered in any patient who presents with
proptosis or inflammation (“streaking”) of the orbital fat. Findings in orbital cellulitis and who has risk factors for mucormycosis (e.g.,
orbital cellulitis usually include proptosis, streaking of the intraconal poorly controlled diabetes mellitus, hematologic malignancies, immu-
fat, and edema of the medial rectus muscle. In subperiosteal or orbital nosuppression, deferoxamine therapy). In contrast with typical bacte-
abscess, there is a low-density mass effect with or without enhance- rial orbital cellulitis, patients with rhinocerebral mucormycosis may
ment.109 An air-fluid level within the mass is even more specific for have minimal lid erythema, more pain in the forehead or temple than
abscess.110 Lateral displacement of the medial rectus and displacement in the eye, and early onset of decreased sensation in the first and second
of the periosteum away from the lamina papyracea are findings that divisions of cranial nerve V. Invasive sinus aspergillosis usually invades
suggest subperiosteal abscess (Fig. 118-8). CT results alone lead to from the sphenoid sinus and may manifest as a subacute orbital apex
misdiagnoses, however, and cannot always be relied on to determine syndrome.
the need for surgery. In one study, CT missed the diagnosis for 2 of 10
subperiosteal abscesses and 1 of 5 orbital abscesses.109 Another review Therapy
of 159 patients with orbital complications of sinusitis described 4 Preseptal cellulitis due to sinusitis should be treated with antibiotics
patients who developed blindness from orbital abscess.111 The abscess active against S. aureus, S. pneumoniae, and H. influenzae. Antibiotics
was not diagnosed by CT in any of these four patients before surgery. should be given intravenously at first in very young children because
If orbital apex syndrome is suspected, magnetic resonance imaging they may be bacteremic. In older children and adults with mild pre­
(MRI) or high-resolution CT with slice thickness of 3 mm or less, septal cellulitis due to sinusitis, initial antibiotics may be oral (e.g.,
or both, should be obtained.109a If cavernous sinus thrombosis is sus- amoxicillin-clavulinate). In cases of preseptal cellulitis due to second-
pected, MRI with venography (MRV) should be performed. Findings ary infection of skin lesion, antibiotics that are also active against
in cavernous sinus thrombosis include flattening or bowing of the MRSA should be considered.
lateral wall of the cavernous sinus (best viewed on coronal images) and All patients with orbital cellulitis should be treated with intrave-
filling defects within the contrast-enhancing cavernous sinus.98 Dila- nous antibiotics and monitored closely for signs of visual compromise.
tion of the superior ophthalmic vein due to venous obstruction is an Depending on the severity of the clinical presentation and likelihood
indirect sign of cavernous sinus thrombosis. Contrast-enhanced thin of MRSA as a pathogen, initial broad-spectrum antibiotics could
section CT also has a very high sensitivity for detecting cavernous include either intravenous ampicillin-sulbactam or the combination
sinus thrombophlebitis, and CT is the usual initial study performed in of intravenous vancomycin, metronidazole, and ceftriaxone. If Pseu­
patients who present with orbital infections. In a retrospective study domonas is a consideration (e.g., patients who are immunocompro-
mised, have known sinus colonization with Pseudomonas, or who have
received multiple antibiotics in recent months), then an antipseudo-
monal agent should be included. Clinical worsening should prompt a
repeat CT scan and consideration of surgical exploration of the orbit.
Sinus drainage surgery should also be considered if sinusitis is present.
Older children and adults with subperiosteal abscess require
prompt surgical drainage in addition to broad-spectrum intravenous
antibiotics, such as the combination of intravenous vancomycin,
metronidazole, and ceftriaxone (or ceftazidime if Pseudomonas is a
concern). An antibiotic, such as vancomycin, that is active against
MRSA should be included initially for these serious infections, given
the increased incidence in recent years, as discussed earlier. The need
for immediate drainage of subperiosteal abscess in young children is
controversial. Some authors recommend a trial of intravenous antibi-
otics in children younger than 9 years who have a medial subperiosteal
abscess that is not large and who do not have frontal sinusitis, visual
decrease, chronic sinusitis (e.g., nasal polyps), or infection of dental
origin.117 These authors recommend performing visual and pupillary
examinations every 6 hours for at least 48 hours and immediate surgery
if the child remains febrile for more than 36 hours, develops visual loss
or afferent pupillary defect at any time, worsens after 48 hours, or fails
to improve after 72 hours. Other authors advocate immediate surgical
drainage in all patients, citing a 10% rate of blindness in this infection
without prompt drainage.118 These authors also note that it may be
FIGURE 118-8  Computed tomography scan of subperiosteal impossible to obtain frequent and accurate assessments of visual acuity
abscess. in young, acutely ill children. A third group recommends a trial of

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 1438
intravenous antibiotics only if vision is normal and close monitoring Broad-spectrum combination antibiotic therapy (e.g., vancomycin,
is possible.107 Surgical drainage does not always require an external metronidazole, ceftriaxone) should also be used as initial therapy for
incision. A nasal endoscopic approach has proved successful in drain- acute bacterial cavernous sinus thrombosis until culture results are
ing medial subperiosteal abscesses in some patients.107,118 available. Because this infection carries a high risk of intracranial com-
Part II  Major Clinical Syndromes

All patients with orbital abscesses should have immediate surgical plications (e.g., brain abscess, subdural empyema), any regimen should
drainage, in addition to initial broad-spectrum empirical therapy. include antibiotics that cross the blood-brain barrier. In septic cavern-
Combination therapy with vancomycin, metronidazole, and ceftriax- ous sinus thrombosis, surgical drainage of the primary focus of infec-
one will provide coverage for most pathogens; it is usually important tion (e.g., sinusitis or dental abscess) should be performed and patients
to initially include an antibiotic active against MRSA given the increas- should be monitored closely for any intracranial extension that may
ing incidence of this organism. Antibiotics may be simplified (e.g., to require surgical drainage.118a The use of anticoagulation has been con-
ampicillin-sulbactam) following drainage if cultures reveal sensitive troversial, but some studies suggested it was beneficial when started
organisms. early in patients who had no evidence of hemorrhage.119,120

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Chapter 118  Periocular Infections

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