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. 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. 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. 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. 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. 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. 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. 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. 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.
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
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
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
22. 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
23. 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
24. Coronal CT scan in a pediatric patient
with sinusitis as well as an orbital and
subperiosteal abscess (Left Side)
25. Coronal CT scan in a pediatric patient
with sinusitis and orbital abscess.
26. 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
29. 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
30. 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
31. 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
32. 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
33. 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
35. 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
37. 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
38. 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
40. 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