AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Periorbital infections comprise a group of infections that can be broadly classified into two distinct groups. One group consists of infections of the dermis and associated tissues around the eyes. The other group consists of infections of the lacrimal system.

Infections of the superficial skin around the eyes are called periorbital or preseptal cellulitis. These infections are limited to the area anterior to the orbital septum. The orbital septum is a fibrous membrane that extends from the periosteum of the orbit as the arcus marginalis and lies just deep to the orbicularis oculi muscle. In the upper lids, the septum fuses with the levator aponeurosis. In the lower lids, the septum fuses with the capsulopalpebral fascia.¹ The orbital septum acts as a physical barrier to the spread of infection.

Infections of the lacrimal system are classified based on the location of the infection. The lacrimal system includes the structures involved in production and drainage of tears. The lacrimal gland is located in the lateral upper lid margin. It produces about 10 mL of secretions per day. In the process of blinking, the eyes close from lateral edge to the medial edge pushing the tear film across the surface of the eye. Most of the tear volume is lost by evaporation. A small portion is drained from the lacrimal lake located at the inner canthus through the puncta and into the superior and inferior canaliculi. Tears then flow into the common canaliculus and lacrimal sac. The lacrimal duct, which lies within the bone, connects the lacrimal sac with the eventual site of egress, the inferior meatus of the nose.¹

Blepharitis is an inflammation of the lid margins. Anterior blepharitis affects the area of the lid where the eyelashes attach. Posterior blepharitis affects the inner portion of the eyelid margin that is in contact with the eye.

Dacryoadenitis is inflammation of the lacrimal gland. Dacryocystitis is inflammation of the lacrimal duct or sac. Canaliculitis is inflammation of the canaliculi.

Pathophysiology

Periorbital cellulitis

Periorbital cellulitis can occur by several mechanisms.

• Infection as a result of local trauma including insect bites
• Infection as a result of spread from contiguous structures such as in conjunctivitis, hordeolum, lacrimal system infections, and impetigo
• Infections secondary to hematogenous spread during bacteremia due to nasopharyngeal pathogens
• Infections secondary to sinusitis causing venous and lymphatic congestion: The sinusitis may be of odontogenic origin.² A thorough examination of dentition may be warranted.

Blepharitis

• Anterior blepharitis is usually caused by bacteria that colonize the base of the eyelashes. If the pilosebaceous glands of Zeiss and Moll become infected an abscess will occur. This abscess is known as an external hordeolum or stye.³ Cell-mediated immunologic mechanisms have been implicated in the development of chronic blepharitis.⁴
• Posterior blepharitis is caused by Meibomian gland dysfunction. The Meibomian gland secretes an oily layer of the tear film. If the secretions become inspissated, causing plugging of the gland, a chalazion may develop. A chalazion is a noninfectious granulomatous reaction. If there is infection secondary to plugging, an internal hordeolum develops.⁵

Dacryoadenitis

• Dacryoadenitis is caused by local infection of the lacrimal gland by bacteria or viruses.
• Dacryoadenitis associated with inflammation and swelling of the salivary glands is called Mikulicz syndrome. This is considered a subtype of Sjögren syndrome.⁶

Dacryocystitis

• Dacryocystitis is caused by inflammation of the lacrimal sac; this usually occurs in the setting of obstruction of the lacrimal apparatus.
• The obstruction may be congenital, secondary to infection, tumor, or trauma.¹

Canaliculitis

• Canaliculitis is caused by infection of the canaliculi; usually, it is chronic.
• It may also be iatrogenic after instrumentation or placement of silicone plugs in the treatment of dry eyes.⁷

Sex

No gender predominance exists.

Age

Periorbital cellulitis is predominantly a pediatric disease.⁸

Obstructed lacrimal ducts causing dacryocystitis are common in infants and usually resolve by age 9-12 months.⁹

Blepharitis affects primarily older persons, with a mean age of 50 years.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Periorbital cellulitis
• • An antecedent history of insect bite, trauma to the periorbital skin, infection of adjacent structures, upper respiratory infection, or sinusitis may be present.
  • A sudden increase in temperature and rapid swelling of tissue may occur.
  • A history of underlying illness (eg, HIV acute lymphoblastic leukemia), which would increase the patient's risk of infection, may be present.
• Anterior blepharitis
• • Erythema, pruritus, and crusting of lid margins
  • Typically without discharge
• Posterior blepharitis
• • Epiphora
  • Foreign body or burning sensation¹⁰
  • Blurred vision, photophobia
• Dacryoadenitis
• • Swelling of upper lateral eyelid
  • Scleral injection
  • If caused by a viral infection, the area is modestly tender. Bacterial causes result in more severe tenderness.
• Dacryocystitis
• • A history of chronic conjunctivitis or recent upper respiratory infection may be present.
  • Epiphora
  • Fever
  • Swelling, tenderness, and erythema usually localized of the medial canthal area
  • Purulent discharge
• Canaliculitis
• • Epiphora
  • Irritation or pruritus of medial portion of affected eyelid

Physical

• Periorbital cellulitis
• • Erythema, swelling, and tenderness of the lids without evidence of orbital congestion (proptosis, decreased extraocular movement)
  • Fever
  • Vesicles if associated with herpetic infection
  • Violaceous discoloration of the lid is more commonly associated with Haemophilus influenzae but may be associated with infection with Streptococcus pneumoniae.¹¹
  • If associated with trauma, there may be a break in the skin overlying the area of cellulitis.
• Anterior blepharitis
• • Crusting at the base of the lash (known as scurf or collarettes), erythema of lid
  • Usually, no discharge
  • Poliosis, or whitening of the lash, may occur.³
  • If associated with ocular rosacea, telangiectatic vessels may be noted on the lid margins and cheeks.¹²
  • In chronic cases, ulceration of the lid, lid notching (tylosis), thinning of eyelashes (madarosis), or misdirection of the eyelashes (trichiasis) may be noted.
• Posterior blepharitis 
• • Decreased Schirmer score
  • Conjunctival hyperemia¹³
• Dacryoadenitis
• • Soft tissue swelling that is greatest at the lateral portion of the upper lid margin¹⁴
  • Deforms the upper lid into a characteristic S-shape⁹
  • If caused by a viral infection, the area is modestly tender. Bacterial causes result in more severe tenderness.¹⁵
  • Decreased Schirmer score
• Dacryocystitis: Pressure on the area overlying the lacrimal sac may cause expression of purulent material from the lacrimal puncta.
• Canaliculitis
• • Edematous, "pouting" punctum
  • Erythema of adjacent conjunctiva
  • Mucous regurgitation from punctum on application of pressure
  • Yellowish concretions may be expressed from the punctum. These are sulfur granules produced by Actinomyces israelii.

Causes

• Periorbital cellulitis¹⁶
• • When associated with trauma
  • • Staphylococcus aureus: This may include methicillin-resistant Staphylococcus aureus¹⁷ and treatment should be tailored to local incidence of infection. 
    • Streptococcus pyogenes (group A streptococci)
  • In the absence of trauma
  • • Streptococcus pneumoniae
    • H influenzae type b was the predominant cause prior to the advent of the Hib vaccine but has now only been shown to cause rare cases.^{8, 18, 19, 20}
  • Other unusual causes 
  • • Neisseria gonorrhoeae²¹
    • Neisseria meningitidis^{22, 23}
    • Vaccinia virus²⁴ in a laboratory worker has been reported. Autoinoculation in patients receiving the vaccine has been reported.²⁵
    • Herpes simplex virus
    • Mycobacterium tuberculosis²⁶
    • Bacillus anthracis²⁷
• Blepharitis
• • Anterior blepharitis
  • • Almost exclusively caused by Staphylococcus species³
    • Other bacteria include Propionibacterium acnes and Moraxella species.⁹
    • Helicobacter pylori is associated with blepharitis; however, cause and effect has not been established.²⁸
    • Viruses - Herpes simplex virus, herpes zoster virus, and human papillomavirus
    • Mites - Demodex folliculorum and Demodex brevis²⁹
    • Lice - Phthirus pubis causing the condition known as phthiriasis palpebrarum³⁰
    • Noninfectious entities such as ocular rosacea and seborrheic dermatitis may also cause anterior blepharitis.
  • Posterior blepharitis - Meibomian gland dysfunction
• Dacryoadenitis
• • Bacteria – This is most often caused by gram-positive cocci, usually staphylococci. It may also be caused by Streptococcus pneumoniae.
  • Viruses - Prior to increased immunization rates, the mumps virus was most often implicated. Now, the Epstein-Barr virus is most often associated with chronic dacryoadenitis.³¹
• Dacryocystitis
• • Dacryocystitis usually occurs as a result of obstruction of the lacrimal system, which may be congenital, infectious, tumor, inflammatory, or traumatic.
  • Infectious causes include most commonly gram-positive isolates in 78% (Staphylococcus and Streptococcus species) and gram-negative isolates in 22%.³²
• Canaliculitis
• • It is classically taught that the most common pathogens of canaliculitis are Actinomyces israelii and Nocardia (formerly known as Streptothrix) species.⁹
  • Recent case reviews have shown mixed flora associated with infection. Species isolated include Staphylococcus species, Escherichia coli, Haemophilus species, Pseudomonas aeruginosa, Klebsiella oxytocia,³³ Arcanobacterium (previously Corynebacterium) haemolyticum, and Mycobacterium chelonae.³⁴
  • Iatrogenic - Instrumentation or plugging

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Periorbital cellulitis

• Angioedema
• Bites, insect
• Cavernous sinus thrombosis
• Chalazion
• Internal and external hordeola
• Idiopathic orbital inflammation, also known as orbital pseudotumor³⁵
• Mucormycosis
• Nephrotic syndrome
• Orbital cellulitis
• Pott puffy tumor³⁶

• Basal cell carcinoma
• Squamous cell carcinoma
• Sebaceous cell carcinoma
• Actinic keratosis
• Keratoacanthoma

Dacryoadenitis

• Sjögren syndrome
• Sarcoidosis
• Tumors cause about 25% of lacrimal gland enlargement.³⁸

Canaliculitis

• Carcinoma³⁹
• Melanoma

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Periorbital cellulitis
• • Complete blood count (CBC) with differential is not routinely necessary. It may be helpful if bacteremia or sepsis is a concern.
  • Blood cultures may be performed if bacteremia or sepsis is a concern.
  • Skin culture has a very low yield.
• Dacryoadenitis
• • CBC with differential and blood culture may be performed if bacteremia or sepsis is a concern.
  • Serology testing may be indicated if a viral etiology needs to be established.
• No laboratory studies are indicated for routine use in dacryocystitis, blepharitis, and canaliculitis.

Imaging Studies

• Periorbital cellulitis
• • Computed tomography (CT) of the orbits should be performed to rule out orbital and subperiosteal involvement and cavernous sinus thrombosis. CT also helps to distinguish sinusitis as cause.
  • Indications for CT include inability to perform a full evaluation of the eye due to edema or patients with proptosis, ophthalmoplegia, decreased visual acuity or color vision, bilateral periorbital edema, or central symptoms.⁴⁰ 
  • CT will show lid edema but no proptosis or "streaking" of the orbital fat, which lies posterior to the orbital septum.
  • MRI is the study of choice to rule out cavernous sinus thrombosis.
  • Patients whose condition fails to improve after 24-36 hours of appropriate antimicrobial therapy should also have CT performed.⁴⁰
• Canaliculitis: 20-MHz ultrasound can be used to detect sulfur granules within the canaliculi.⁴¹

Procedures

• Periorbital cellulitis: If infection with H influenzae type b or Streptococcus pneumonia is suspected or if systemic involvement is present, a lumbar puncture is indicated to exclude meningeal infection.
• Blepharitis: Biopsy may be indicated in some cases to rule out malignancy.
• Dacryoadenitis: Lacrimal gland biopsy may be indicated in chronic disease.
• Schirmer test is used to assess tear production. It is nonspecific as to the etiology of dry eyes.
• Jones dye test is used to assess patency of the lacrimal drainage system. In the first part of the test, a drop of fluorescein is placed in the conjunctival cul-de-sac. After 5 minutes, the nose is examined for the presence of dye. If no dye is present, an obstruction is present and the second part of the test is performed. A cannula is placed into the lacrimal sac, which is then washed with saline. If no fluorescein is noted, the dye is obstructed in the upper (canalicular) portion of the system. If dye is present, then the obstruction is in the lower (sac, duct) portion.⁴²

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Emergency Department Care

• Periorbital cellulitis
• • In adult patients who are nontoxic and can be assured of appropriate follow-up, treatment can be with oral antibiotics on an outpatient basis.
  • Most pediatric patients require admission. Intravenous antibiotics should be started. Once clinical improvement is noted, the patient should be switched to oral antibiotics.
  • Patients who undergo outpatient treatment should be seen daily to ensure clinical improvement.
  • Nasal decongestants may be used for the short term to reduce mucosal edema.⁴⁰
  • A Clinical Severity Index has been established for periorbital cellulitis in children. It uses systemic features of interaction and fever and local features of location, erythema, extent, and pain and tenderness.⁴³
• Blepharitis
• • The treatment of blepharitis, regardless of etiology, begins with eyelid hygiene. The patient should be instructed to wash the lids with a nonirritating baby shampoo or a commercially prepared lid scrubbing solution and to use warm compresses for 15 minutes at a time, 3 or 4 times a day.
  • For blepharitis suspected to be infectious in nature, a topical antibiotic, such as bacitracin or erythromycin, should be prescribed. The frequency and duration of treatment should be determined based on the severity of the disease process.⁴⁴ Usually, it is applied 2-4 times a day for 2 weeks.
  • Posterior blepharitis may be treated with an oral tetracycline, which decreases lipase production in staphylococci preventing plugging of Meibomian glands. This therapy is limited to patients older than8 years due to the risk of tooth enamel discoloration.⁴⁴ Alternative treatment with the macrolide, erythromycin, is safe for use in children younger than 8 years.⁴⁵
  • Topical cyclosporine has shown benefit in treatment of posterior blepharitis in a small study of 30 patients compared to treatment with tobramycin/dexamethasone.
  • A brief course of preservative-free topical steroids has been shown to decrease ocular surface inflammation.
  • If blepharitis is caused by Demodex infestation, treatment with weekly lid scrubs with 50% tea tree oil and daily scrubs with tea tree shampoo for a minimum of 6 weeks has been shown to decrease mite load and improve inflammatory responses.
  • Phthiriasis palpebrarum is treated with twice-daily application of petrolatum for 7-10 days. Alternatively, removal of the nits and lice can be accomplished with forceps.  
• Dacryoadenitis
• • Treatment of acute dacryoadenitis is largely supportive as the disease is usually self-limiting. Use warm compresses and nonsteroidal anti-inflammatory drugs.
  • If the etiology is bacterial, antibiotic treatment with a first-generation cephalosporin should be started.
  • If the etiology is EBV, steroids have been shown to improve the clinical course.
  • For chronic dacryoadenitis, treat the underlying condition.
• Dacryocystitis
• • Treat with oral antibiotics such as amoxicillin-clavulanic acid or dicloxacillin.
  • In pediatric patients, the obstruction usually resolves by age 9-12 months. Many pediatric ophthalmologists will wait until after this age to probe the ducts to free the obstruction.
  • Dacryocystorhinostomy is the surgical procedure of choice. This procedure allows for the bypassing of the lacrimal duct apparatus as long as the canalicular apparatus is intact.
  • Punctal dilation and nasolacrimal irrigation is contraindicated in the acute stage due to the increased risk of periorbital cellulitis.
• Canaliculitis
• • Remove concretions with gentle pressure using a cotton swab.
  • Warm compresses
  • Irrigation with penicillin solution to be performed by an ophthalmologist
  • Systemic antibiotics, usually penicillin or amoxicillin for 1-2 weeks
  • Topical antibiotics - Bacitracin or erythromycin: This rarely achieves complete resolution due to inability of antibiotics to penetrate concretions.
  • Canaliculotomy with curettage is the definitive treatment.

Consultations

• Consider consultation with an ophthalmologist for any patient who may have orbital involvement.
• Most cases of lacrimal system infections can be managed conservatively. Consultation with an ophthalmologist is indicated if the condition is not resolved within 24-48 hours.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The goals of pharmacotherapy are to eradicate the infection, prevent complications, and reduce morbidity.

Drug Category: Antibiotics, systemic

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Further inpatient care is indicated for the treatment of periorbital cellulitis in the pediatric population for the administration of intravenous antibiotics.
• Further inpatient care is indicated in any patient who is septic or has orbital involvement.

Complications

• Periorbital cellulitis
• • Toxic shock syndrome
  • Eschar formation leading to scarring
  • Meningitis
  • Orbital cellulitis
  • Necrotizing fasciitis has been described in a case of periorbital cellulitis in an immunocompromised patient
• Blepharitis
• • Hordeolum
  • Chalazion
  • Scarring of the cornea, which could lead to blindness
  • Trichiasis (misdirection of eyelashes)
  • Corneal infection
• Dacryocystitis 
• • Dacryocystitis may be associated with periorbital cellulitis. Rarely, it may be associated with orbital cellulitis or abscess formation. This is usually prevented by the orbital septum, which surrounds the lacrimal sac.
  • Complications may occur during a dacryocystorhinostomy, including hemorrhage, infection, and CSF leakage.
• Canaliculitis - Epiphora

Prognosis

• Periorbital cellulitis - With appropriate antibiotics, the prognosis is good.
• Blepharitis - Typically, this is a chronic disease with waxing and waning of symptoms.
• Dacryoadenitis
• • Prognosis of the acute form is excellent as it is a self-limiting process.
  • Prognosis of the chronic form depends on the underlying disease process.
• Dacryocystitis - Success rates for dacryocystorhinostomy are good. External procedures fare better due to the ability to create a larger ostium.
• Canaliculitis - Prognosis is excellent with definitive treatment by canaliculotomy with curettage.

Patient Education

• Periorbital cellulitis - For excellent patient education resources see eMedicine's patient education article, Cellulitis.
• Blepharitis 
• • Blepharitis Fact Sheet is available for purchase from the American Academy of Ophthalmology.
  • The use of eye makeup, especially eyeliner, can cause acute exacerbations by plugging the glands.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to recognize orbital involvement

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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Article Last Updated: Nov 18, 2008