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Ophthalmology (Eye Conditions)

Orbital Cellulitis

A serious, acute infection and inflammation of the soft tissues within the bony orbit, posterior to the orbital septum. Differentiated from preseptal cellulitis which affects tissues anterior to the septum (eyelid only).

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Referral and warning signs

When to refer

IMMEDIATE URGENT REFERRAL to Hospital (H/RR) with Ophthalmology/ENT capability for ALL suspected cases of orbital cellulitis. This is an ophthalmic and potentially life-threatening emergency.

Red flags

  • Proptosis (bulging eye).
  • Pain or limitation of eye movements.
  • Decreased vision.
  • Relative Afferent Pupillary Defect (RAPD).
  • Signs of systemic toxicity / sepsis.
  • Altered mental status / Neurological signs (suggests intracranial spread).

Signs and symptoms

  • Key Features Distinguishing from Preseptal Cellulitis:
  • - Proptosis: Bulging/protrusion of the eyeball.
  • - Ophthalmoplegia: Pain or restriction with eye movements.
  • - Decreased Visual Acuity.
  • - Relative Afferent Pupillary Defect (RAPD): May be present.
  • Other Common Signs/Symptoms:
  • - Eyelid swelling and redness (erythema).
  • - Conjunctival injection and chemosis (swelling).
  • - Eye pain (often deep, aching).
  • - Fever, malaise, headache.
  • - History of recent sinusitis, dental infection, facial/eyelid infection, or orbital trauma.

Risk factors

  • Sinusitis (especially ethmoiditis) - most common cause.
  • Dental infections.
  • Facial infections (skin, eyelid - impetigo, erysipelas).
  • Orbital trauma (penetrating injury, fracture).
  • Recent eye surgery.
  • Dacryocystitis (infection of lacrimal sac).
  • Immunosuppression.

Diagnosis

Clinical assessment

Clinical diagnosis based on presence of eyelid swelling/redness PLUS at least one orbital sign (proptosis, ophthalmoplegia, decreased vision, RAPD). High index of suspicion needed.

Investigations

  • CT Scan (Orbit and Sinuses) with contrast: Essential imaging modality to confirm diagnosis, assess extent of infection, identify abscess formation, evaluate sinuses.
  • MRI Scan: Alternative or complementary, better for soft tissue/cavernous sinus.
  • Full Blood Count (FBC): Leucocytosis.
  • Blood Cultures.
  • Culture of nasal discharge or drained sinus/abscess material.

Diagnostic criteria

Clinical orbital signs (proptosis, ophthalmoplegia, vision loss) +/- confirmation on CT/MRI scan.

Differential diagnosis

  • Preseptal Cellulitis (eyelid swelling/redness ONLY, no proptosis, normal eye movements, normal vision).
  • Cavernous Sinus Thrombosis (bilateral signs, cranial nerve palsies, severe headache, sepsis).
  • Orbital pseudotumour (inflammatory, may mimic infection).
  • Orbital tumour (e.g., rhabdomyosarcoma in children, lymphoma).
  • Thyroid eye disease (usually bilateral, slower onset, other thyroid signs).

Management

Non-pharmacological management

  • Urgent Hospital Admission.
  • Close monitoring of vision, pupillary reactions, eye movements, proptosis.
  • Consultation with Ophthalmology and ENT specialists.

Pharmacological treatment

  • Prompt Broad-Spectrum IV Antibiotics: Cover common sinus pathogens (Staph aureus, Strep pneumoniae, other streptococci, Haemophilus influenzae, anaerobes).
  • - e.g., Ceftriaxone PLUS Vancomycin OR Clindamycin.
  • - OR Ampicillin/Sulbactam.
  • - Tailor based on suspected source, local resistance patterns, culture results.
  • - Continue IV until significant clinical improvement (fever resolved, proptosis/inflammation decreasing), then consider switch to appropriate oral antibiotics to complete 2-3 week course.
  • Nasal decongestants (if sinusitis present).

Monitoring

Frequent monitoring of visual acuity, pupils, eye movements, proptosis. Monitor temperature, WBC count, clinical response to antibiotics. Repeat CT scan if worsening or no improvement.

Complications

  • Vision loss (optic nerve compression/ischaemia).
  • Cavernous sinus thrombosis.
  • Meningitis.
  • Brain abscess.
  • Subperiosteal or orbital abscess.
  • Exposure keratopathy (due to proptosis).

Prevention

  • Prompt and adequate treatment of sinusitis, dental infections, facial infections.
  • Complete childhood immunizations (Hib, PCV).

Patient education

  • Explanation of the seriousness of the infection.
  • Need for urgent hospital admission and IV antibiotics.
  • Potential need for CT scan or surgery.
  • Importance of completing full antibiotic course.
  • Potential risks to vision.
  • Follow-up requirements.

Uganda-specific notes

Must differentiate from preseptal cellulitis which can be managed outpatient. Orbital cellulitis requires urgent hospital admission and IV antibiotics (Ceftriaxone widely available). CT scan access is limited. Consider underlying causes like sinusitis.

Surgical Management

  • Surgical Drainage: Indicated for orbital abscess, sinus drainage if sinusitis is the cause, or if vision threatened/no improvement with IV antibiotics.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 20, Section 20.1.7

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