Pearl of the Day: Periorbital Infections

Periorbital Infections Periorbital Cellulitis - infection of eyelids and periocular tissues anterior to orbital septum - average age: 2 years; most patients < 10 years - spreads from local infection (e.g., conjunctivitis, dacryoadenitis, dacryocystitis, hordeolum), paranasal sinusitis, hematogenous spread from nasopharyngeal pathogens, upper respiratory tract infections - most common pathogens: S. pneumoniae, Streptococcus pyogenes, H. influenzae, Moraxella catarrhalis

Signs/Symptoms - erythematous, tender, swollen, warm eyelid and periorbital area - excessive tearing - no limitation in extraocular muscles, proptosis, pain with eye movement, normal visual acuity - may have difficulty opening eyelid

Management - may require CT scan of orbits to rule out orbital cellulitis - well-appearing, afebrile -> oral antibiotic therapy (e.g., amoxicillin-clavulanate, cephalexin) - severe periorbital cellulitis -> IV antibiotic therapy (e.g., ceftriaxone + vancomycin)

Blepharitis - inflammation of lid margins - anterior blepharitis: inflammation of eyelid where eyelashes attach, usually infectious in nature - posterior belpharitis: inflammation of inner portion of eyelid margin in contact with eye, usually due to dysfunction of meibomian gland - average age: 40 - 50 years - most common etiology: reaction to deltalike toxin from overgrowth of S. epidermidis - symptoms: conjunctival injection, crusting, pruritic eyelids, photophobia, occasionally eye pain - treatment: daily cleansing of edges of eyelids and eyelashes, warm compresses; severe cases require erythromycin or bacitracin-polymyxin ointment

Dacryocele - small bluish-hued palpable mass at nasolacrimal duct without conjunctival erythema or discharge - due to obstruction at valve of Hasner and common canaliculus - treatment: urgent referral to ENT or ophthalmology for possible marsupialization

Dacryoadenitis - inflammation of lacrimal gland - chronic dacryoadenitis is caused by noninfectious inflammatory disorders (e.g., Sjogren's, sarcoidosis, thyroid disesase) - acute dacryoadenitis is usually infectious (from EBV, mumps virus, coxsackievirus, CMV, VZV, S. aureus, streptococci, Neisseria gonorrhea, Chlamydia trachomatis, Brucella melitensis) - viral dacryoadenitis causes less intense discomfort and erythema - treatment: mild infections can be treated with oral first-generation cephalosporin (e.g., cephalexin) or trimethoprim/sulfamethoxazole if MRSA is suspected; severe infections require IV antibiotics (e.g., nafcillin, vancomycin)

Dacryocystitis - inflammation of lacrimal duct or sac usually caused from obstruction - common pathogens:  Streptococcus pneumoniae, staphylococci, Haemophilus influenzae - initial chronic mucopurulent discharge that progresses to erythema and swelling to inframedial eye - usually secondary bacterial infection following viral upper respiratory infection - diagnosis: applying gentle pressure with finger or cotton swab applied to nasolacrimal sac causes reflux of mucopurulent material (should be cultured) - if improperly treated, can lead to periorbital and orbital cellulitis - treatment: usually requires hospital admission with IV antibiotics (e.g., cefuroxime, cefazolin, clindamycin, +/- vancomycin)

Resources Tintinalli's Emergency Medicine, 8th Edition Periorbital Infections, Medscape,