Orbital cellulitis is a diffuse purulent inflammation of the orbital fiber. Orbital cellulitis is characterized by a severe general condition (headache, nausea, febrile fever), pulsating pain in the orbit, exophthalmos, diplopia, edema and hyperemia of the eyelids, conjunctival chemosis, decreased visual acuity, limited mobility of the eyeball. Diagnosis involves establishing a connection between the disease and purulent infections (sinusitis, facial boils, dacryocystitis, complicated orbital injuries, etc.), radiography, ultrasound, CT of the orbit and paranasal sinuses, orthopantomograms. Treatment requires systemic and topical use of antibiotics, autopsy and drainage of orbital cellulitis.
Orbital cellulitis is a serious problem in surgical ophthalmology. Despite its relatively low occurrence (about 1% of cases in the population), orbital cellulitis can pose a danger not only to visual function, but also to the patient’s life. When the purulent process spreads through the venous bed from the orbit into the cranial cavity, dangerous complications develop – cerebral vascular thrombosis and meningitis, which in 20% of cases lead to the death of patients. orbital cellulitis can occur at any age, but is more common in children under 5 years of age.
The development of orbital cellulitis is etiopathogenetically closely associated with purulent diseases of the eyes, paranasal sinuses, dental and maxillary system, skin, facial skeleton injuries, and general infections.
About 70% of cases of orbital cellulitis are orbital complications of sinusitis, especially ethmoiditis. Purulent melting of orbital fiber can also be caused by the penetration of infection from nearby foci of inflammation: teeth and jaws (with osteomyelitis of the upper jaw, periodontal abscess), facial skin (with furunculosis, erysipelas), eyes (with barley, dacryocystitis, phlegmon of the eyelid, infected orbital injuries, complicated foreign bodies of the eye), etc. Less often, the cause of orbital cellulitis is purulent metastasis in sepsis, complicated course of common infections (influenza, scarlet fever, typhus).
Orbital cellulitis, as well as phlegmons of other localization, in most cases is caused by Staphylococcus aureus and white, hemolytic and greening streptococcus, less often — Pneumobacillus, diplococcus, E. coli. Pathogens penetrate the ocular tissue through the facial veins and veins of the orbit, which do not have valves. At the same time, small pustules are formed at first, then merging into large abscesses.
The purulent process in the orbital fiber develops in stages, passing through the stages of preseptal cellulite, orbital cellulitis, subperiosteal abscess and abscess proper and orbital cellulitis. At the same time, timely therapy can interrupt the further development of inflammation at any stage.
Preseptal cellulite is characterized by inflammatory edema of the tissues of the orbit and eyelids, minor exophthalmos, but the mobility of the eye at this stage is preserved, and vision is not impaired. Further progression of the infectious process and its spread to the posterior parts of the eye socket causes the development of orbital cellulitis. This form is clinically manifested by edema of the eyelids, exophthalmos, chemosis, limited mobility of the eyeball and decreased visual acuity. If pus accumulates between the periorbital and the bone wall of the orbit, leading to the destruction of the latter, a subperiosteal abscess of the orbit is formed. At this stage, there is swelling and hyperemia of the upper eyelid, impaired mobility and displacement of the eyeball in the direction opposite to the location of the abscess, exophthalmos, impaired visual acuity.
An abscess of the orbit is characterized by an accumulation of pus in the orbital tissues with the formation of a cavity bounded by a pyogenic membrane. In addition to the above-mentioned signs of purulent orbital inflammation, ophthalmoplegia, compression of the optic nerve and blindness may develop with an eye socket abscess. With a diffuse inflammation of the orbital fiber, they talk about the phlegmon of the eye socket.
Purulent inflammation in the phlegmon of the eye socket is usually unilateral and rapid development (from several hours to 1-2 days). At the same time, there is a throbbing pain in the eyelids and eye socket, which increases with movements of the eyeball and palpation. The eyelids are sharply swollen, have a red-purple hue, are tense, they cannot be opened. As the inflammation increases, infringement of the conjunctiva in the eye slit (chemosis), diplopia, exophthalmos, displacement and immobility of the eyeball, a sharp decrease in vision develops. With phlegmon of the eye socket, the general condition of the patient rapidly worsens: malaise, headache, nausea, fever increases.
During the transition of the inflammatory process to the optic nerve, neuritis develops, thrombotic occlusion of retinal veins, neuroparalytic keratitis with the formation of purulent corneal ulcers. When involved in purulent inflammation of the vascular and other membranes of the eye, choroiditis and panophthalmitis occur, followed by atrophy of the eye.
Critical complications of orbital cellulitis can be brain abscess, meningitis, venous sinus thrombosis, sepsis. A relatively favorable outcome of orbital cellulitis can be considered a spontaneous breakthrough of pus through the conjunctiva or the skin of the eyelid outwards.
A patient with orbital cellulitis should be immediately consulted by an ophthalmologist, an otolaryngologist and a dentist. The diagnosis of orbital cellulitis is facilitated by the analysis of anamnestic data: the presence of previous purulent processes of the maxillofacial region, a characteristic clinical picture, external examination of the eye with the help of an eyelid lifter, palpation.
The necessary instrumental diagnostics includes ultrasound and radiography of the orbit, ultrasound and X-ray examination of the paranasal sinuses, orthopantomogram. For clarifying purposes, diaphanoscopy, ophthalmoscopy can be used to assess the condition of the optic nerve, exophthalmometry, biomicroscopy, CT of orbits, etc. From laboratory tests with ophthalmic phlegmon, general clinical blood analysis and blood culture for sterility are of primary diagnostic importance.
Orbital cellulitis should be differentiated from phlegmon of the eyelid, acute dacryocystitis, tenonitis, periostitis of the orbital wall, foreign body of the orbit, retrobulbar hemorrhage, glioma, sarcoma, neurofibromatosis, Quincke’s edema.
Treatment of orbital cellulitis
In case of orbital cellulitis, emergency hospitalization and immediate initiation of therapy are indicated. Shock doses of broad-spectrum antibiotics and symptomatic agents, detoxification therapy are prescribed. In addition to parenteral administration of antimicrobials, subconjunctival and retrobulbar injections are performed.
At the same time, ethmoidotomy, maxillofacial surgery with trepanation of the orbital wall, puncture and drainage of the paranasal sinus with washing and administration of drugs are performed. If there are areas of fluctuation, an orbitotomy is performed; the wound canal is drained with a turunda soaked in an antibiotic solution. In the future, the incisional cavity is washed with drugs to which the bacterial flora is sensitive.
Additionally, with phlegmon of the eye socket, instillations of antibacterial drops and fortified solutions into the conjunctival sac are prescribed; if it is possible to open the eyelids, ointments are applied to the conjunctiva and cornea. Subsequently, drug therapy is supplemented with physiotherapy – UHF, UFO.
Prognosis and prevention
Active treatment undertaken in the initial stages of orbital cellulitis contributes to a favorable outcome of the disease. However, in the long-term period, there may be limited mobility of the eyeball, secondary strabismus and amblyopia, corneal thorn, optic nerve atrophy. The progression and spread of purulent infection can lead to panophthalmitis, brain abscesses, meningitis, cavernous sinus thrombosis, generalized sepsis with fatal outcome.
Prevention of orbital cellulitis requires timely sanitation of purulent foci of the skin of the face, ENT organs, dental system, eyes. In case of foreign bodies and mechanical damage to the eyes, mandatory antibiotic prophylaxis of infectious complications is necessary.