survey of ophthalmology 63 (2018) 534e553 Available online at www.sciencedirect.com ScienceDirect journal homepage: www.elsevier.com/locate/survophthal Major review Orbital cellulitis Theodora Tsirouki, MD, PhDa, Anna I. Dastiridou, MD, PhDa, Nuria Iba´nez flores, MDb, Johnny Castellar Cerpa, MDb, Marilita M. Moschos, MD, PhDc, Periklis Brazitikos, MD, PhDd, Sofia Androudi, MD, PhDa,* a Department of Ophthalmology, University of Thessaly, Larissa, Greece b Institut Catala` de Retina, Barcelona, Spain c Department of Ophthalmology, University of Athens, Athens, Greece d 2nd Department of Ophthalmology, Aristotle University, Thessaloniki, Greece article info abstract Article history: Orbital cellulitis (OC) is an inflammatory process that involves the tissues located posterior Received 23 December 2016 to the orbital septum within the bony orbit, but the term generally is used to describe Received in revised form 22 infectious inflammation. It manifests with erythema and edema of the eyelids, vision loss, November 2017 fever, headache, proptosis, chemosis, and diplopia. OC usually originates from sinus Accepted 7 December 2017 infection, infection of the eyelids or face, and even hematogenous spread from distant Available online 15 December 2017 locations. OC is an uncommon condition that can affect all age groups but is more frequent in the pediatric population. Morbidity and mortality associated with the condition have Keywords: declined with advances in diagnostic and therapeutic options; however, OC can still lead to orbital cellulitis serious sight- and life-threatening complications in the modern antibiotics era. Therefore, intracranial abscess prompt diagnosis and treatment remain crucial. Antibiotic coverage, computed tomo- orbital abscess graphy imaging, and surgical intervention when needed have benefitted patients and vision loss changed the disease prognosis. We review the worldwide characteristics of OC, predis- antibiotics posing factors, current evaluation strategies, and management of the disease. diagnosis ª 2017 Elsevier Inc. All rights reserved. management 1. Introduction pediatric population, with an incidence of 1.6 per 100,000 and 0.1 per 100,000 in children and adults, respectively.129 Orbital cellulitis (OC) is an inflammatory process that involves Morbidity and mortality of OC have declined with improve- the tissues located posteriorly to the orbital septum within the ment in diagnosis and therapy32; however, since it may still bony orbit, but the term generally is used to describe infec- have serious complications, prompt diagnosis and treatment tious inflammation. It is not as common as preseptal cellulitis are crucial.108,158,196 We review the worldwide characteristics that affects tissues anterior to the orbital septum. OC is of OC, predisposing factors, infectious causes, and current encountered at all age groups but more frequently affects the evaluation and management of the disease. * Corresponding author: Sofia Androudi, MD, PhD, Department of Ophthalmology, University of Thessaly, Larissa 412 22, Greece. E-mail address: [email protected] (S. Androudi). 0039-6257/$ e see front matter ª 2017 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.survophthal.2017.12.001 survey of ophthalmology 63 (2018) 534e553 535 of OC compared to sinusitis in the age group 6e16 years.11 In 2. Predisposing factors India, injury was associated with OC in 24% of cases132 and was usually linked to the presence of a foreign body.108,195 The most frequent predisposing factor in all age groups is Foreign body OC is caused either by organic materials or secondary infection extending from the paranasal sinuses. This by metal objects (Fig. 1). Usually children and young males is established in studies in both the Western and the devel- are affected because injuries are caused during playing or at 32,34,85,188,191 oping world. Specifically, it has been determined work.49 Organic foreign bodies usually involve wood. e e that 1.3% 5.6% of sinusitis results in OC, and 0.3% 5.1% Wooden foreign bodies carry a large amount of bacteria, and 6,151 develop orbital or subperiosteal abscess. OC most if not promptly removed, they lead to severe infections.179 commonly originates from the ethmoid sinuses, with a re- These injuries are associated with a high risk of OC and 22,61,68,76,82,113,127 ported frequency of 43% to as high as 94.7% of complications such as recurrent cellulitis, cutaneous fistula, 53 cases in a study from Canada and 100% in another study from restrictive myopathy, periorbital abscess, and even pan- 8 Massachusetts. The infection proceeds from the sinuses to the ophthalmitis.164 Identification of the wooden foreign bodies orbit, assisted by specific anatomical characteristics such as the with CT can be difficult. During the first days after the injury, thin medial orbital wall, lack of lymphatics, valveless veins of wooden foreign bodies appear as low-density signal on CT 104 the orbit, and foramina of the orbital bones. scan and may be misdiagnosed as air. After a few months the Surveys that detect sinusitis radiologically find up to 91% of wooden material presents the same density as the sur- cases of sinus-related OC originate from the ethmoid and rounding tissues, making it difficult to diagnose.105 In certain 30,58 maxillary sinus. In a 10-year retrospective analysis from cases, additional imaging with magnetic resonance imaging e Taiwan, however, children aged 3 18 years diagnosed with (MRI) and especially T1-weighted images may further OC underwent computed tomography (CT) scans, and the enhance the ability to identify a wooden or vegetable foreign involved sinuses, in the order of frequency, were maxillary, body.179 Timely removal of these foreign bodies leads to 83 ethmoid, frontal, and sphenoid. In fact, childhood OC in- resolution of inflammation and associated signs.110 Metal 34,62 volves more than 1 sinus in up to 38% of cases. In a study objects are more easily identified and surgically removed from Canada, pansinusitis was observed in 15.7% of cases in from the orbit; however, most metals are inert and, 58 children. In adults, OC may be related to frontal sinus depending on their location in the orbit, may be treated 75,84,120 infection, whereas multiple sinus involvement does conservatively without removal.83 Iron, copper, and lead, 34,62 not exceed 11%. however, may cause serious complications, and gunshot Spread of the infection from the upper respiratory tract to injuries usually lead to severe ocular injury.28 the orbit is also a major cause of OC.35,38,103,176 The affinity of In Nigeria, upper respiratory tract infections and facial and OC with infections arising from the sinuses and the upper globe injuries were reported as the major predisposing factors respiratory tract reflects the seasonal distribution of the dis- for OC.14 Additionally, in children, insect bite (10%), hordeo- 34,62 ease, with peak occurrence in winter to early spring. This lum, and molluscum contagiosum of the lid with secondary is proportional to the seasonal distribution of infections bacterial infection were common predisposing factors.141 initiating in the aforementioned anatomical locations.32 In developed countries, OC is not common after ophthalmic Reported etiological factors of OC also differ between surgery; however, there are rare reports of OC after strabismus Western and developing countries. Trauma or surgery is a surgery,4,19,48 blepharoplasty,93 canaliculitis surgery,80 cataract common cause of OC in developing countries.14,32,62,90 OC surgery,101 peribulbar injection,5,84,108,120,189 sub-Tenon anes- follows either direct inoculation from a penetrating injury or thesia,111 hydroxyapatite35 and polyethylene98 orbital sockets, develops secondarily to orbital fracture that allows comm- implanted aqueous drainage devices, keratoprosthesis, and unication between the sinuses and the orbit.104 In a study silicone-sponge scleral buckle implants for rhegmatogenous from Pakistan, trauma was reported as a more common cause retinal detachment.3,132 Fig. 1 e Foreign body causing endophthalmitis and orbital cellulitis. A: Photo of a patient with an intraocular foreign body of the left eye and B: axial CT scan of the orbits. A metal intraocular foreign body with the entry wound in the medial conjunctiva is causing endophthalmitis and orbital cellulitis of the left orbit. Although removal of metallic foreign bodies is not always necessary, the foreign body in this case must be removed. CT, computed tomography. 536 survey of ophthalmology 63 (2018) 534e553 Other etiological factors of OC include dacryocystitis, dental presented within 3 days of disease onset.14 The average re- infections from spread through the maxillary sinus,45,46 ported duration of symptoms was 5.2e10.6 days, and average endophthalmitis, panophthalmitis,142 untreated preseptal hospital stay was 9e13.7 days in the developing countries, with cellulitis, and hematogenous spread in the setting of bacter- 57.6% of cases presenting a prolonged hospital stay of more e emia from distant sources.5,30 32,34,39,62,63,65,108,125,138 In a study than 10 days.14,65,139,141 In contrast, in the Western countries, from Saudi Arabia, intraocular or orbital tumorsdspecifically the average duration of symptoms was 4.4 days, and the retinoblastoma, rhabdomyosarcoma, and melanomadwere average hospital stay was 5.8e6.2 days.58,62,130 the underlying cause in 3.7% of patients with OC.34,128 Finally, right and left orbits are almost equally affected, Finally, there are also case reports