Preseptal Versus Orbital Cellulitis in Children: An Observational Study.

BACKGROUND: Preseptal and orbital cellulitis are two types of infection surrounding the orbital septum with very different potential outcomes. Our aim was to describe key differential features of both conditions, laying special emphasis on diagnostic and therapeutic tools. METHODS: A retrospective review of patients admitted to a tertiary hospital over a 15-year period (January 2004-October 2019) was conducted. We included 198 patients with preseptal and 45 with orbital cellulitis. Descriptive statistics were performed to examine the available information. RESULTS: Statistically significant differences were found between patients with preseptal and orbital cellulitis regarding age (3.9 ± 2.14 vs. 7.5 ± 4.24 years), presence of fever (51.5% vs. 82.2%), and preexisting sinusitis (2% vs. 77.8%) (all P < 0.001). Diplopia, ophthalmoplegia and proptosis were only present in orbital cellulitis (P < 0.001). Median values of C-reactive protein were significantly higher among children with orbital involvement [136.35 mg/L (IQR 74.08-168.98) vs. 17.85 (IQR 6.33-50.10), P < 0.0001]. A CRP>120 mg/L cut-off point for orbital cellulitis was obtained. Early CT scans were performed in 75.6% of suspected orbital cellulitis and helped detecting complications at an early stage. Abscesses were revealed in 70.6% of cases, especially medial subperiosteal abscesses (58.8%). All patients received intravenous antibiotics, whereas corticosteroids were preferred in patients with orbital implication (8.6% vs. 73.3%, P < 0.001). Only 26.7% of patients required additional surgery. CONCLUSIONS: Clinical presentation and CRP are extremely sensitive for differential diagnosis of preseptal and orbital cellulitis. Prompt initiation of intravenous antibiotics is mandatory and can prevent surgical procedures even in cases with incipient abscesses.

Unilateral periorbital swelling in children: avoid delays in diagnosis.

A 10-year-old child had painful periorbital swelling in the left eye. It was diagnosed as preseptal cellulitis and treated with oral antibiotics. Three days later, the ocular condition worsened so the child was referred for further management. On examination, the child had a temperature of 102 °F. Ocular examination revealed proptosis, restricted ocular movements and a relative afferent pupillary defect in the left eye. Ocular examination of the right eye was normal. There was a history of recurrent episodes of cold in the past. CT scan orbit and sinuses revealed signs of orbital cellulitis with sinusitis on the left side. The child was treated with parenteral antibiotics and endoscopic sinus surgery. A child presenting with unilateral periorbital swelling needs to be thoroughly evaluated. It is important to differentiate orbital cellulitis from preseptal cellulitis. Orbital cellulitis is an emergency and delay in diagnosis can lead to vision and life-threatening intracranial complications.

Indicators for imaging in periorbital cellulitis secondary to rhinosinusitis.

PURPOSE: Our objective was to identify the clinical indicators for subperiosteal orbital abscess (SPOA) among patients who present with periorbital cellulitis secondary to rhinosinusitis, and to evaluate the need for performing a computerized tomography (CT) scan. METHODS: A retrospective cohort study of all patients admitted to our tertiary care emergency department between 2006 and 2014 was conducted. Included were healthy patients with acute periorbital cellulitis secondary to rhinosinusitis. Variables analyzed included age, gender, duration of symptoms, previous antibiotic therapy, highest recorded temperature, physical examination findings, ophthalmologist's examination results, laboratory results, and interpretation of imaging studies, when performed. RESULTS: Of the 123 identified patients, 78 (63%) were males, with a mean age of 4 years (range 1-70). 68 patients were categorized as Chandler's 1 disease, 2 as Chandler's 2, and 53 as Chandler's 3. 68 patients underwent a CT scan, of those 53 had SPOA. Proptosis and ophthalmoplegia were strongly associated with the presence of an abscess (P < 0.001). However, 14 patients with no ophthalmoplegia or proptosis who underwent a CT scan were older (mean age, 10 years; P < 0.028), and had higher neutrophil count of 78 versus 59% (P = 0.01). This group of patients had a clinically rapidly progressive disease, receiving wider broad-spectrum antibiotics or had their antibiotic treatment replaced to broader spectrum antibiotics through their course of treatment (48.2% compared to only 6.1%). CONCLUSIONS: We confirmed that patients with proptosis and/or limitation of extraocular movements are at high risk for developing SPOA, yet many do not have these predictors. Other features can identify patients who do not have proptosis and/or limitation of extraocular movements but do have significant risk of SPOA, and in these cases performing an imaging study is strongly suggested.

Odontogenic orbital cellulitis associated with cavernous sinus thrombosis and pulmonary embolism: a case report.

BACKGROUND: This case illustrates the importance of prompt assessment and treatment of orbital cellulitis. In fact the ocular signs and symptoms may be associated with systemic complications which should be investigated and identified as soon as possible to avoid a poor prognosis. CASE PRESENTATION: A 46-year-old white woman presented to our emergency room with proptosis, ophthalmoplegia, and conjunctival chemosis of her left eye. An ophthalmologist, having diagnosed orbital cellulitis in her left eye, suspected a cavernous sinus thrombosis. Hematochemical and radiological examinations confirmed the cavernous sinus thrombosis and also showed septic pulmonary embolism. A blood culture indicated Streptococcus constellatus, which is a member of the Peptostreptococcus family, a saprophyte of the oral mucosa that can be pathogenic in immunocompromised persons. The odontogenic origin was then confirmed by dental radiography which showed a maxillary abscess. Her eye signs regressed after antibiotic and anticoagulant therapy. CONCLUSIONS: This complex case shows the importance of a multidisciplinary approach for the management of orbital cellulitis, for the prompt diagnosis and treatment of eye injuries and possible complications, so as to avoid serious and permanent sequelae.

A Case Series and Review of Bisphosphonate-associated Orbital Inflammation.

PURPOSE: To report the largest series of new cases to date of bisphosphate-associated orbital inflammation. METHODS: A retrospective case review of patients with orbital inflammation following treatment with systemic bisphosphonate. RESULTS: Six patients over an 18-month period (2 males, 4 females) with an average age of 62.2 years had onset of orbital inflammatory symptoms 1-11 days after intravenous bisphosphonate infusion or, in 1 case, 4 weeks after initiation of oral bisphosphonate therapy. Imaging revealed diffuse orbital involvement in 3 cases, isolated lateral rectus muscle involvement in 2 cases, and superior rectus-levator involvement in 1 case. Two patients' symptoms resolved spontaneously within 2 weeks, and 3 responded rapidly and completely to corticosteroid therapy. The 1 patient on oral bisphosphonate had a slower but complete response to corticosteroid treatment. CONCLUSION: Clinicians should be aware of the association between acute orbital inflammation and recent treatment with systemic bisphosphonate medication.

Bisphosphonate-Induced Orbital Inflammation: A Case Series and Review.

INTRODUCTION: To present a series of patients with bisphosphonate induced orbital inflammation, and to review the clinical presentation, radiological features, treatment options and outcomes. METHODS: We present a multicentre, retrospective case series review of patients with a clinico-radiological diagnosis of bisphosphonate induced orbital inflammation and review all the reported cases of this complication in the literature. RESULTS: Four new patients with bisphosphonate induced orbital inflammation were added to the 25 cases in the literature. Intravenous zoledronate was the commonest precipitant (22/29, 75.9%) and inflammation occurred 1-28 (mean 3) days post-infusion. Orbital imaging identified orbital inflammation in 22/29 cases and extra-ocular muscle enlargement in 8/29. Five patients presented with reduced vision of which one - with anterior ischaemic optic neuropathy - did not resolve. The vision resolved in all except one patient, with most requiring steroid treatment. CONCLUSIONS: Bisphosphonates have a pro-inflammatory effect, which can precipitate orbital inflammation. This rare, but potentially serious complication of bisphosphonate treatment should be considered by clinicians using bisphosphonate treatment and by ophthalmologists seeing patients with orbital inflammatory disease.

Adalimumab as steroid-sparing treatment of inflammatory-stage thyroid eye disease.

PURPOSE: Steroids are often used as medical therapy for active thyroid eye disease (TED). While high-dose steroids have been shown to be effective in reducing the severity of TED symptoms, the side effects of steroids can be severe. As the pathogenesis of TED is thought to involve the upregulation of proinflammatory cytokines, including tumor necrosis factor-α (TNF-α), it has been postulated that anti-TNF agents may be used as steroid-sparing agents in the treatment of TED. This retrospective study was conducted to examine the efficacy of adalimumab, a subcutaneously administered TNF-α antagonist, in treating the inflammatory symptoms of active TED. METHODS: All patients in the inflammatory phase of TED who were treated with adalimumab at the Jules Stein Eye Institute over a 2-year period were reviewed. Data concerning visual acuity, optic nerve function, extraocular motility restriction, binocular visual fields, and proptosis were extracted from patient charts. Clinical photographs from baseline and 3-month follow-up visits were reviewed by masked orbital specialists. Each photograph was graded on the severity of conjunctival injection, chemosis, eyelid erythema, and eyelid edema on a scale from 1 to 4. An inflammatory score was calculated as the sum of these 4 elements. Groups were compared using paired t tests. RESULTS: Six of 10 patients showed a decrease in inflammatory score while on adalimumab, whereas 3 showed an increase and 1 stayed the same. One patient experienced a significant complication (hospital admission for sepsis). Eight patients received concomitant tapering steroids during the first 6 weeks of therapy as the adalimumab reached maximum efficacy. When data from all 10 subjects were analyzed together, there was no significant change in inflammatory index after 3 months of treatment with adalimumab. However, when the 5 patients with a high baseline inflammatory index (>4) were considered separately, there was a significant improvement (mean decrease of 5.2±2.7; p<0.01) after adalimumab treatment. Four of 5 patients also reported a subjective improvement in symptoms while on adalimumab. CONCLUSIONS: This study suggests that adalimumab may have a role in the treatment of active TED with prominent inflammatory symptoms. The use of adalimumab and other immunosuppressive agents in the treatment of TED may help to mitigate some of the metabolic and psychiatric side effects of pulsed steroid treatment. A future randomized controlled study will be necessary to determine the efficacy of adalimumab as a primary therapy for TED.

Orbital cellulitis: clinical course and management challenges. the Lagos State University Teaching Hospital experience.

BACKGROUND: Orbital cellulitis is a devastating acute infection of orbital soft tissues located posterior to the orbital septum. It is both vision and life-threatening. It is an ocular emergency which most often present in childhood. OBJECTIVE: This article reviewed cases presenting during the study period with the view of examining the pattern of presentation, clinical course and management challenges. METHODS: A retrospective study was conducted on patients presenting with orbital cellulitis between January 2008 and June 2011. Socio-demographic data, entry and discharge visual acuity, presenting complaints, predisposing factors, duration of complaints, admission period and complications were extracted from clinical records and analyzed. RESULTS: Seventeen (17) patients presented with orbital cellulitis constituting 6.2% of ocular emergency admissions during the study period. Twelve (70.6%) were males. Thirteen (76.5%) were children. The major predisposing factors were upper respiratory tract infections, and facial and globe injuries in five (22.7%) cases respectively. Only five (29.4%), presented within three days of disease onset. Average duration of admission was 10.6 days. Complications during the course of disease were category 4 and 5 blindness in five (23.5%), orbital abscess four (23.5%), cavernous sinus thrombosis two (11.8%), contralateral preseptal cellulitis two (11.8%) and exposure keratopathy in one (5.9%). CONCLUSION: Orbital cellulitis has remained a disease with high ocular morbidity. The major management challenges were poor financial status of patients precluding necessary diagnostic laboratory and imaging studies. Early recognition, diagnosis and treatment are crucial to the preservation of vision and reduced occurrence of complications. The importance of record keeping is also highlighted.

Radiographic predictors of visual outcome in orbital compartment syndrome.

PURPOSE: The goal of this study is to evaluate parameters on orbital CT as predictors of visual outcome in orbital compartment syndrome from retrobulbar hematoma or orbital cellulitis. The study will assess the assertion that certain patients are anatomically predisposed to vision loss in these conditions. METHODS: A retrospective chart review of consecutive patients with the diagnosis of either orbital cellulitis or orbital hematoma from the clinic of a single provider in an academic practice from 2006 to 2009 was performed. Exclusion criteria included preexisting vision loss, lack of CT scan for analysis, or lack of 1-month follow up for final visual acuity. Measurements of final visual acuity, medial wall length, lateral wall length, distance from the globe to the apex, and a novel measurement of posterior globe tenting (stretch angle) were obtained. Patients were divided into 2 groups: normal visual acuity and vision loss. Statistical analysis was performed to identify significant differences between the 2 groups. RESULTS: The normal vision group consisted of 11 patients, all with vision of 20/30 or better. The average length of the medial and lateral wall was 43.9 and 41.6 mm, respectively. The average distance from the globe to the apex was 26.3 mm in the uninvolved eye and 30.3 mm in the involved eye, resulting in an average difference of 4.18 mm. The average stretch angle measurement was 28.9° in the uninvolved eye and 28.5° in the involved eye, resulting in an average difference of 0.41°. The vision loss group consisted of 4 patients, all with vision of count fingers or worse. The average length of the medial and lateral wall was 46.9 and 45.7 mm, respectively. The average distance from the globe to the apex was 32.2 mm in the uninvolved eye and 36.7 mm in the involved eye, resulting in an average difference of 4.50 mm. The average stretch angle measurement was 32.3° in the uninvolved eye and 21.1° in the involved eye, resulting in an average difference of 11.2°. The difference in stretch angle between eyes in the vision loss and normal vision groups were found to be highly significant with a p value of less than 0.001. The difference between the 2 orbits for globe to apex is a rough measurement of proptosis and was not statistically different in the 2 groups (p = 0.71), whereas the length from the globe to the apex in the uninvolved eye was statistically different between the vision loss group and normal vision group (p = < 0.001). CONCLUSIONS: Orbital compartment syndrome is a potentially vision-threatening condition. Minimal objective data are currently available in the literature to guide physicians in making clinical judgments regarding these patients. The results of this study indicate that comparing the novel stretch angle between the patient's 2 eyes and measuring the length from the globe to the orbital apex can help identify patients at risk for poor visual outcome. This study provides objective measurements that can aid ophthalmologists and radiologists in determining the relative threat to vision in patients presenting with orbital compartment syndrome from orbital cellulitis or retrobulbar hematoma. Hopefully, the data can help select patients that may benefit from more aggressive intervention and will ultimately result in superior visual outcomes.

Severe aseptic orbital cellulitis with subtenon carboplatin for intraocular retinoblastoma.

Retinoblastoma is a rare intraocular tumor of childhood. Chemoreduction followed by laser or cryotherapy is the treatment of choice. Subtenon carboplatin injection is also an accepted treatment modality for vitreous seeds, along with systemic chemotherapy. Transient periocular edema, optic neuropathy and fibrosis of orbital tissues are the known side effects of subteneon carboplatin injection. We report a case of severe aseptic orbital cellulitis with necrosis and prolapse of the conjunctiva 48 h after the injection, which resolved well on only conservative management.

Orbital and intracranial complications after acute rhinosinusitis.

BACKGROUND/OBJECTIVES: Nowadays, intracranial abscess is a rare complication of acute rhinosinusitis. The consequent orbital and intracranial complications of acute rhinosinusitis are rare but must be mutually excluded in complicated rhinosinusitis even when proper surgical and medical treatment tend to efficiently heal the orbital complication. METHODS: We report a case of a patient who primarily revealed symptoms of orbitocellulitis as a complication of odontogenous rhinosinusitis. Proper diagnostic and therapeutical measures were undertaken to manage the disease immediately after stationary admission. RESULTS: Two weeks after an inconspicuous healing period, hemiparesis due to formation of an intracranial abscess developed. An emergent situation reveals which was unusual to the clinical situation. CONCLUSION: The possible role of underlying mechanisms of intracranial abscess formation is discussed and review of literature concerning orbital and intracranial rhinosinusitis complications is performed. The correct indication of imaging methods and accurate evaluation of diminutive symptoms are essential. We assume that performance of a complementary CT of the brain or MRI even when previous CT scan of the orbit/paranasal sinuses reveals no cerebral pathology should be done to avoid or minimize future patients with consecutive orbital and intracranial complications of acute rhinosinusitis.

Exaggerated postsurgical inflammation in a patient with insufficiently treated Addison disease.

A patient with Addison disease developed fever, pain, and marked orbital inflammation 3 days after evisceration in the setting of perforated corneal ulcer. He was treated for presumed orbital cellulitis without improvement. Increasing the corticosteroid dose for his Addison disease resulted in complete resolution of the inflammation.

Preseptal and orbital cellulitis: 15-year experience with sulbactam ampicillin treatment.

The infection of the orbita and ocular tissues can result in severe local and systemic complications. We aimed to determine the predisposing factors for preseptal and orbital cellulitis, the clinical and routine laboratory differences between orbital and preseptal cellulitis, and the change in the spectrum of the pathogens and the antibiotics used in the last 10 years. One hundred thirty-nine patients, hospitalized in Hacettepe University Faculty of Medicine Children's Hospital between 1 January 1990 and 31 December 2003 with diagnosis ofperiorbital or orbital cellulitis, were reviewed retrospectively. Ten of the patients (7%) had orbital and 129 (93%) had preseptal cellulitis. The male/female ratio was 1.7:1. The average age (mean+/-standard deviation) was 5.7+/-4 years. The seasonal distribution was most marked in spring and fall periods. When compared with preseptal cellulitis, the mean blood cell count, erythrocyte sedimentation rate and C-reactive protein levels were significantly higher in patients with orbital cellulitis. Staphylococcus aureus was isolated in 13 (41.9% of total microbiologically confirmed cases), coagulase-negative staphylococcus in 8 (25.8%), and H. influenza type b in 2 patients (6%). Thirty out of 77 clinical sample cultures (39%) were positive. In clinical studies, etiological agents of orbital and preseptal cellulitis could be identified in only 20-30% of cases, so in clinical practice treatment is usually empiric. We observed that sulbactam-ampicillin was a safe and effective choice of treatment in orbital and preseptal cellulitis in our cases.

Predictors for admission of children with periorbital cellulitis presenting to the pediatric emergency department.

OBJECTIVES: To identify demographic and clinical characteristics associated with admission because of periorbital cellulitis (PC) in children. METHODS: Records of children aged 0 to 18 years with PC who visited our tertiary emergency department (ED) in 2004 were reviewed. We calculated a cumulative number of local ocular symptoms in patients that included swelling/edema, redness/erythema, presence of discharge, pain, conjunctival injection, and shut eye. A binary logistic regression analysis was performed to identify predictors of admission for PC. RESULTS: A total of 89 children were included in the analysis; 39 (44%) of them were admitted to the ward. A cumulative number of local symptoms associated with PC and temperature in the ED served as significant predictors of hospitalization (odds ratio, 2.5; P = 0.005; and odds ratio, 2.0; P = 0.04, respectively). Among individual local symptoms, only swelling/edema was found to significantly predict admission in univariate analysis (P = 0.03). Considerable variation was documented in intravenous and oral antibiotics prescribed in the ED. CONCLUSIONS: Combination of local ocular symptoms and body temperature are positively associated with admission from the ED. Future research should concentrate on evaluating the suggested score we used in this cohort to validate it and evaluate its generalizability. Devising such scoring can help clinicians determine guidelines for admission of children with PC.