Eye Pain and Swelling

An 85 year-old man presented to the ED with a two day history of gradually increasing right eye pain and swelling.  His visual acuity was 20/30 bilaterally and no afferent pupillary defect was noted.  His exam is shown in the two videos below.

   


What is your diagnosis and why is this case a bit unusual?  How would you manage this case?

Orbital Cellulitis

This patient presented with a severe case of orbital cellulitis, with several interesting features.

Periorbital (preseptal) cellulitis is an infection lying anterior to the orbital septum. It is usually associated with swelling of the eyelid, discoloration of the orbital skin, redness, and warmth. Vision, extraocular movements, pupillary findings, and optometric examinations are normal. Orbital cellulitis tends to have similar but more severe symptoms than preseptal cellulitis. Signs of orbital cellulitis - in which inflammatory cells and bacteria invade posterior to the orbital septum to infiltrate the orbital tissues - include proptosis, decreased ocular mobility, ocular pain, and tenderness on eye movement.  Limited extraocular movement on the right is evident on the videos on the preceding page.

Orbital cellulitis is more common in children than in adults.  In one series of 303 patients with orbital cellulitis, 68% of the patients were younger than the age of 9 years (1).  A case of orbital cellulitis is indeed unusual in an 85 year-old patient.  Moreover, in adults, orbital cellulitis is typically seen in the setting of chronic sinusitis.  80-90% of cases in adults are associated with sinusitis (2).   As is evident on the CT images below, this patient did not have sinusitis.

Orbital cellulitis generally results from extension of infection from the periorbital structures, most commonly from the paranasal sinuses, but also from the face, globe, and lacrimal sac.  Other etiologies include direct inoculation of the orbit from trauma or surgery and hematogenous spread from bacteremia. The etiology in this particular patient was not determined.

Differentiation of periorbital (preseptal) from orbital cellulitis is an important clinical decision that affects management and prognosis. If orbital cellulitis is suspected based on history and examination, a CT scan of the orbit is indicated to evaluate for subperiosteal or intraorbital abscess formation.  Images from this patient's CT scan follow.  No abscess was found and, as noted, sinusitis is not evident.  This patient's CT was notable for considerable edema of the right orbit anteriorly.  There is mild proptosis of the right eye.  Soft tissue inflammation extends posteriorly primarily at the medial aspect of the right orbit

Early periorbital (preseptal) cellulitis may be followed on an outpatient basis for the first 24 to 48 hours of antibiotic therapy, with daily follow-up to determine whether resolution is occurring. A broad-spectrum antistaphylococcal agent provides appropriate coverage. Treatment for orbital cellulitis includes hospitalization, intravenous (IV) antibiotics, and occasionally incision and drainage. Broad-spectrum antibiotic coverage of H. influenzae, S. aureus, Streptococcus pyogenes, and anaerobes is indicated. This patient did well with IV cefuroxime.

If orbital cellulitis progresses, thrombophlebitis may develop and extend intracranially to cause cavernous sinus thrombosis. Hallmarks of cavernous sinus thrombosis include bilateral cranial neuropathy and central neurologic impairment.


References:


(1) Mawn LA, et al. Preseptal an Orbital Cellulitis Ophthalmology Clinics of North America 2000; Volume 13, Number 4

(2)Barone ST, et al. Periorbital and orbital cellulitis in the Haemophilus influenzae vaccine era, J Pediatr Ophthalmol Strabismus 1997; 34:293

(3) Steinkuller PG, Jones DB: Microbial preseptal and orbital cellulitis. In: Tasman W, ed: Clinical Ophthalmology. Philadelphia : Lippincott, Williams & Wilkins; 1999: Chapter 25, 1-8, 17-29.

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