| Fact | Explanation |
|---|---|
| Introduction | Orbit is a corn like bony space in the anterior skull. It mainly contains eye ball, ocular muscles, nerves and blood vessels. both orbits anteriorly eye ball connect with outer space posteriorly with the brain, superiorly with frontal sinus, inferiorly with maxillary(medially) and sphenoidal sinuses(laterally) and medially with ethmoidal sinus. Structures passing throught superior orbital fissure are oculomotor nerve, abducent nerve, naso ciliary branch of ophthalmic branch of trigeminal nerve and orbital veins. Optic nerve passes via optic foramen. Maxillary division of trigeminal nerve, zygomatic nerve, branches from the sphenopalatine ganglion and branches of inferior ophthalmic vein passes throught inferior orbital fissure. Maxillary division of trigeminal nerve passes via inferior maxillary groove. Anotomy of orbit and related structures are very important in identifying the aetiology, symptoms and complications of orbital infections[1][2][3]. |
| fever, headache and other constitutional symptoms like malaise, lethargy, fatiguability | fever, headache and other constitutional symptoms will be present due to the presence of an infection. In a presence of an abscess patient will have high grade fever[1][2]. |
| Pain in the eyes and pain causing limitation of the eye movements | Patients will complain pain eye pain it can be a continuous pain, or in early disease pain will present with movements of the eye ball. Pain is mainly due due to the inflammation of orbital muscles and swelling causing increased pressure in side the orbit. And also caused by the palsy of pupillary and ocular muscles causing limitation of eye functioning (poor vision may lead to eye pain). In periostitis pain can spread around the orbit as well. Pain will be deep, more towards the evening and will associated with headache and vomiting[1][3]. |
| Swelling and redness around eyes and eye lids | inflammation causes these symptoms[1][3]. |
| Redness of the eye | Chemosis following inflammatory processes (venous occlusion) causes painful red eye[5][6]. |
| Numbness of the forehead | Due to the inflammatory process following infection, nerve compression can cause numbness over supplying divisions (eg; ophthalmic branch of trigeminal nerve supply the forehead sensation)[7][8]. |
| Photophobia | Corneal damage, optic neuritis secondary to infection and dysfunction of pupils may lead to photophobia in a orbital infection. Afferent pupilary nerves can affect causing poor control over controlling the light entering to the eyes( due to afferent pupillary defects)[11][12]. |
| eye ball projecting out than usual | exophthalmos can develop following all infections of the orbit due to the increased intra-orbital pressure with soft tissue swelling and abscess formation[3][14]. |
| Ulcers and pus discharging sinuses/ purulent nasal discharge | Especially in periostitis of the orbital rim leads to abscess formation ultimately leading to ulceration and discharging fistula formation. This may be present as a purulent nasal discharge. These fistula common around eye lid and in chronic disease process like in osteomyelitis, these ulcers and fistulas can heal with fibrous formation causing contraction leading to eye lid deformities[13]. |
| Visual impairment | Compression of the optic nerve can cause visual problems this may range from mild visual impairment to sudden total loss of vision( sustained compression leads to optic nerve ischemia. Corneal damage (eg:direct trauma, keratitis), optic neuritis and blockage of ocular blood supply leads to visual problems[9][10]. |
| Features suggestive of cavernous sinus thrombosis | Cavernous sinus thrombosis is a complication of orbital infections. patient will have headache, periorbital pain, swelling and cranial nerve palsy ( Eg; Lateral gaze palsy with isolated cranial nerve VI, eye muscle weakness with 3rd cranial nerve palsy)[15][16]. |
| Features suggestive of brain abscess | Patient will have high grade fever, headache and focal neurological symptoms. Severity of the symptoms will depend on the size(usually occur in frontal lobe) and site of the abscess. Abscesses can be intracranial, epidural or subdural. Patient will persist symptoms despite of antibiotic therapy[17][18]. |
| Features suggestive of meningitis | Patient will have severe headache, photophobia, fever and altered behavior[19][20]. |
| History of recent upper respiratory tract infections, Chronic sinusitis. | paranasal sinusitis (headache, rhinorrhoea), periodontal abscesses (tooth ache with fever, tooth extraction), nasolacrimal infection (excessive tearing, pain/swelling of the medial aspect of the eye), otitis media(earache) and pharyngitis( difficulty/ pain during swallowing) like infections can leads to orbital cellulitis[3][21]. |
| History of direct impact on eye | Direct trauma to eye/surrounding structures, ophthalmic surgeries, foreign body in eye, insect bites can also leads to orbital infections[3][20][22]. |
| Past history of lesions of the eye lid and lacrimal sac or past history of eyelid swelling, eye pain or excessive tearing. | lesions of the eyelids and lacrimal sac by some infections like tuberculosis, syphilis and fungal infections can ultimately go into orbital infections especially periostitis of the orbit[23][24]. |
| past history of diagnosed retinoblastoma or rhabdomyosarcoma in children or breast carcinoma | Necrotic tumors like retinoblastoma, rhabdomyosarcoma will present as cellulitis of the orbit(aseptic). secondary metastatic deposits from primary cancers like breast cancers can also produce similar symptoms[25][26]. |
| features of septicaemia | In this case patient will be ill with constitutional symptoms, dizziness, there may be features of organ damage. Septicaemia can lead to cellulitis by haematogenous spread of the infections[3][20]. |
| Age | orbital infections are more common in younger population while it is more severe in adults[2][3]. |
| sex | In adult population there is no difference in sex distribution but in paediatric and young population males are at risk of developing orbital infections than females[4]. |
| Fact | Explanation |
|---|---|
| General examination patient will be ill looking, in pain and febrile | patient will have fever and other constitutional symptoms following infection of the orbit. Temberature should be measure and a chart should be maintained if the patient is in ward. In a presence of an abscess patient will have high grade fever[1][2]. |
| Inspection of the eye | 1) redness of eye lids and surrounding- Swelling and redness around the eye lids and surrounding area is caused by inflammation[1][3]. 2) Ptosis with swelling of eye lids- Swelling of the eye lids and surrounding area is caused by inflammation. Due to the swelling and presence of abscesses of the eye lid patient will have ptosis of the affected eye[1][3]. 3) chemosis- Chemosis occur following inflammatory processes (venous occlusion) and conjuctivitis. So this results painful red eye[4][5]. 3) ulceration of the eye lid and pus discharging fistulas- Especially periostitis of the orbital rim and in osteomyelitis leads to abscess formation ultimately leading to ulceration and discharging fistula formation. These fistula common around eye lid and in chronic disease process like in osteomyelitis 4) deformed eye lid- Ulcers and fistulas can heal with fibrous formation causing contraction leading to eye lid deformities like ectropion and entropian[6][7]. 5) Limted eye movements- Pain causes limitation of the eye movements which occur following inflammation and swelling of the orbital soft tissues and occular muscle palsy can also limit the movements[1][3]. 6) eye ball deviation- In the presence of orbital abscesses eye ball deviation can be seen to contralateral side due to the space limitation. Occular muscle palsy also can be a cause for this[8][9][10]. 7) exophthalmos- Soft tissue swelling with inflammation, abscess formation and osteomyelitis can cause protrusion of the eye ball causing exopthalmos[3][11]. 8) look for any evidence of surgical/ traumatic scars- Direct trauma to eye/surrounding structures, ophthalmic surgeries, foreign body in eye, insect bites can also leads to orbital infections. |
| palpation of surrounding of the eye | 1) warmth and tenderness- Due to the inflammatory process the surrounding soft tissues will be warm and tender[1][2][3]. 2) crepitations over the bony segments- If the patient is having osteomyelitis of the orbital rim there will be tenderness over the orbital rim and crepitations can be feel[1][3][15]. 3) reduced/ absent sensation over fore head- Numbness/ absent sensation of the forehead is due to the inflammatory process. Following the infection nerve compression which are passing through the orbit can cause numbness over supplying divisions (eg; ophthalmic branch of trigeminal nerve supply the forehead sensation)[16][17]. |
| Visual acuity | Compression of the optic nerve can cause visual problems this may range from mild visual impairment to sudden total loss of vision( sustained compression leads to optic nerve ischemia). Corneal damage (either with direct impact or infection causing keratitis), optic neuritis and blockage of ocular blood supply also leads to visual problems[18][19]. |
| colour vision | Optic neuritis following infection of the orbit cause red colour blindness and patient will see red objects as pink or orange. Can use Ishihara color charts for assessment[20][21]. |
| visual fields | Visual field can limit following limitation of the eye movement and also with development of optic neuritis (eg: central scotomas, diffuse vision loss, hemianopia)[22][23]. |
| accormadation and light reflex | Three will be an accommodation and light reflex impairment with orbital infection due to poor pupillary reaction. There will be changes in perception of brightness which can assess using Pelli-Robson chart. So patient will have photophobia. Corneal damage can also leads to this[24][25]. |
| fundoscopic examination | Diffuse disk oedema, blurring of disk margins can be seen during inflammatory process. Prolonged infection/ ischemic conditions may lead to disk atrophy. In presence of an orbital abscess venous engorgement, papilledema will be seen. In retinoblastoma red reflex will be absent[26][27][28]. |
| look for the signs of cavernous sinus thrombosis | Patient will present with ptosis, chemosis, visual defects, cranial nerve palsies (III, IV, V, VI). In fundoscopic examination there will be papilledema and retinal hemorrhages[29][30]. |
| look for the evidence of meningitis/ brain abscesses | In meningitis patients will have fever, headache, photophobia and neck stiffness and there may be altered mental states[31][32]. In brain abscess patient will have high fever and features of space occupying lesion. Symptoms will depend on the site of abscess[33][34]. |
| look for the evidence of any persistent upper/ lower respiratory tract infection. Auroscopic examination for suspected ortitis media. | Patient will have fever, cough, rhinorrhoea, throat inflammation/ inflammed tonsils, ear discharge, tenderness over sinuses, dental caries.This is important as this can leads to orbital infections. (eg; paranasal sinusitis , periodontal abscesses, nasolacrimal infection, otitis media, pharyngitis) Feature suggestive of tuberculosis like loss of weight, low grade fever, chronic cough, haemoptysi and lung fibrosis also important as it leads to orbital infections[3][35]. |
| Look for the evidence of septicaemia | Patient will be ill, hyperthermic, hypotensive, tachycardic, tachypnic and there will be associated features of end organ failure. In septicaemia, haematogenous spread of organisms can cause orbital infections[3][32]. |
| Breast examination (breast lump, ulceration, nipple discharge, skin changes) | This will be useful in suspected case of breast secondaries causing orbital infection[3]. |
| Fact | Explanation |
|---|---|
| cavernous sinus thrombosis | Following other cause of intracranial venous thrombosis patient will present with cavernous sinus thrombosis. The features will be headache, oedematous eyelid, chemosis, proptosis and opthalmoplegia and simptoms of cranial nerve palsy. This can be diagnosed with MRI venogram[3][4]. |
| Acute angle-closure glaucoma | This is an acute presentation of painful red eye associated with severe eye pain, reduction of vision, photophobia, headache, nausea and vomiting. patient will have increased intraocular pressure [1][2]. |
| Homonal imbalance causing graves' disease | In graves disease there will be periorbital oedema, conjunctival irritation, exopthalmos and diplopia. In here patient's will have other thyrotoxic features and investigastions will confirm the thyrotoxicosis[5][6]. |
| Allergy | Alleric condition can leads to redness, itching and swelling of the eye. But tis will be reversible with the removal of the allergen and also it will associated with other symptoms like pruritic skin rash, wheezing, difficulty in breathing[7][8]. |
| Sinusitis | Sinusitis can will give pain over the eye causing visual defects due the pressure following inflammatory condition. symptoms will improve with the improvement of sinisitis. Sinus view of the X ray will confirm the ongoing sinusitis[9][10]. |
| Optic neuritis | This is an inflammatory condition of the optic nerve causing swelling and demyelination. This condition affects the vision of the patient. Other than orbital cellulitis there are common causes like multiple sclerosis which can cause this condition. Patient will have focal neurologcal signs as well. CT scan of the brain will help in identifying the lesions of multiple sclerosis[11][12]. |
| Fact | Explanation |
|---|---|
| Full blood count | this will give an idea of anaemia by haemoglobin level and presence of infection by WBC count[2][3]. |
| ESR, CRP | These test will be high due to the ongoing inflammatory process[4]. |
| Swab from eye dischare and drained pus from orbital abscesses for culture and ABST | This will be helpful in identifying the causative infection and this will support the treatment[5][6][7]. eg: orbital infections -Staphylococcus aureus, Staphylococcus epidermidis, Streptococci, Diphtheroids, Haemophilus influenza, Escherichia coli orbital cellulitis- Haemophilus influenza |
| Blood culture | In suspecting septicaemic condition this will be helpful to identify the organism[8][9]. |
| Contrast-enhanced CT scan/ MRI | This is useful in assessing walls of the orbital, periostium, orbital soft tissues, muscles and optic nerve and associated sinusitis. Contrast enhance CT will make orbital infections more prominent[1]. These also useful in identifying meningitis and brain abscesses[10][11]. |
| ultrasound diagnosis | This is useful in orbital abscess[1][12]. |
| CSF studies( CSF full report, CSF culturs and ABST) | CSF studies will useful in suspecting meningitis[13][14]. |
| Sinus view of the Skull X ray | This will important in suspected sinusitis(with air fluid levels) as predisposing cause of the orbital infection[15][16]. |
| MR venogram | this is more sensitive in diagnosing cavernous sinus thrombosis[17][18]. |
| Chest X ray and sputum for Acid Fast Bacilli | This is useful in suspecting tuberculosis[19][20]. |
| mammogram/ Ultrasound scan of the breast and bone scan. | This will be useful in suspected case of breast secondaries causing orbital infection[21][22]. |
| Thyroid function tests( third generation TSH and T4) | As thyrotoxicosis causing graves' disease, can give similer features these test will be useful in excluding differential diagnosis[23][24]. |
| Fact | Explanation |
|---|---|
| full blood count | This will give an idea of anaemia by haemoglobin level and presence of infection by WBC count during the follow up[1][2]. |
| ESR, CRP | This is useful in assesssing the ongoing inflammatory process[2]. |
| Blood culture | In a suspected septicemic condition this test will be useful during the follow up[3][4]. |
| CT scan/ MRI | As this is useful in assessing walls of the orbital, periostium, orbital soft tissues, muscles and optic nerve and associated sinusitis. CT/ MRI will be useful during follow up to assess the condition of the orbital infetion and also useful in identifying meningitis and brain abscesses[5][6]. |
| Ultrasound scan | This will be useful in assessing the soft tissue of the orbit. Mare important in the presence of orbital abscesses[7][8]. |
| Fact | Explanation |
|---|---|
| Ultrasound scan | This is useful in assessing( respond to treatment) the orbital abscess in followup. Also will useful for ultrasound guided aspiration[1][2]. |
| Fact | Explanation |
|---|---|
| Orbital infections classification by Smith and Spencer and modified by Chandler | Preseptal cellulitis as Group I Orbital cellulitis as Group II Subperiosteal abscess as as Group III Orbital abscess as as Group IV Cavernous sinus thrombosis as as Group V[1][2] |
| ultrasound diagnosis | This is useful in screening the presence of orbital infections[1][3] |
| Fact | Explanation |
|---|---|
| Health education | Patient/ care givers must be educated about the disease, possible predisposing factors, complications associated with the disease, prognosis, investigation options available and treatment options[1][2]. |
| Eye care | This is very important in protecting the eye. Eye should be keep clean and should be handle with sterile glove worn hands. saline socked cotton wools can be used to clean the eyes. Due to the inflammatory process and proptosis eye is more prone to dry causing corneal damage. If the eye is difficult to close it should be cover with a sterile, saline socked gause piece. Artifial tear can use to keep moisture. Need to check the blink response and if the response is absent better to keep the eyes cover and closed. If the eye lid is not closing spontaneously, it should be close manually. Eye need to be examined regularly and complications need to be identify and teat promptly. If there are any predisposing factors for orbital infections as mentioned in the history they should be treated and eye should be regularly monitored [3][4][5][6]. |
| Fact | Explanation |
|---|---|
| Start broad spectrum IV antibiotics | Iv broad spectrum antibiotis (eg; erythromycin, penicillin, chloramphenicol, cephalosporin) should be started as soon as possible after taking blood/eye discharge/ nasal discharge for culture. Drugs should be continued until the reports comes. If the patient is well responding to the already started antibiotics better to continue that thought the reports recommended others. But if the patient is not/ poorly responding report findings will be treatment of choice[1][2]. |
| Drainage of the abscesses | according to the ultrasound scan findings if the abscess it small, patient can be treated with broad spectrum antibiotics and look for improvement. But if the abscess is large/ patient is not responding to the. treatments drainage of the abscess can be consider. Drained pus should be send to culture and ABST, can continue previous IV antibiotic till the report comes and then if needed can shift to another sensitive antibiotic. In here both aerobic and anaerobic organisms should be covered[3][4]. |
| Orbital periostitis treatment | Iv broadspectrum antibiotics should be started after taking the blood and discharge swabs for culture and ABST. If there are associated abcessess incision and drainage must be consider and sample must be send to culture and ABST. If associated fistula present appropriate surgical treatment must be consider (eg: resection/ sequestration)[2][5]. |
| osteomyelitis treatment | Similer to other three conditions treatment should be started with IV high dose broad-spectrum antibioticples. Surgical treatment should be consider for not responding abscesses( incision and drainage) and fistulas (eg:resection/ sequestration). If there are Permanent eyelid deformities (eg: ectropian, entropion) will require surgical correction. With the osteomyelitis there can be underlyinfg bony destruction, necrosis So those should be identify and surgical removal should be done. This will help antibiotics to act on causative organisms. As the superior roof of the orbit is separate the orbital content from the anterior fossa of the skull, osteomylitis involving this part can spread to the skull. So carefull examination should be done to identify any damages and if damages are present repair need to be done[6][7]. |
| Cavernous sinus thrombosis management | Intravenous empiric antibiotic therapy (eg; penicillin, cephalosporin) should be given with anaerobic coverage. This should be given for long duration, at least for one month. Some studies have shown the use of anticoagulant with heparin is life saving and improves the out come. Streptokinase and other fibrinolytic s need to be used via selective catheterization[8][9]. |
| Meningitis management | IV empirical antibiotic treatment (eg; Benzylpenicillin 2.4g IV 6 hourly) should be consider after taking CSF for studies[10][11]. |
| Brain abscess management | First patient should be given IV antibiotics and if not responding surgical evacuation of te abscess should be considered (eg; burr- hole aspiration or excision) as encapsulated abscess will provide a protective medium to persist the infection[12][13]. |
| Treat upper respiratory tract infection/ chronic sinusitis | If this conditions identified as the primary source they should be treated first. eg: 1)Acute coryza- Paracetamol 0.5-1g 6 hourly will improve symptoms, nasal decongestants will be helpful, antibiotics will not necessary in uncomplicated cases. 2) Acute laryngitis- resting, paracetamol and steam inhalation will be useful. 3) Acute laryogo tracheobronchitis- steam inhalation, oxygen therapy will needed, endotracheal intubation/ tracheostomy will relief the symptoms. IV antibiotic therapy (eg;co-amoxyclav, eruthromycin) will helpful in severe disease. 4) Acute bronchitis and tracheitis- Amoxicillin 250mg 8 hourly will be useful. 5) Chronic sinusitis- First can treated with antibiotics (eg; Penicillins, Cephalosporins, Macrolides, Fluoroquinolones) and if not responding drainage can be done. Functional endoscopic sinus surgery proven to be effective in chronic sinusitis[14][15]. |
| If patient is suspected to have neoplastic condition as the primary cause | Surgical treatement,chemotherapy anf radiotherapy will be helpful with the oncologist's openion. Retinoblastoma- Enucliation of the eye will be needed in advanced disease and if bilateral chemotherapy will be needed following retinal laser treatment. Radiotherapy will use in recurrences[16]. Rhabdomyosarcoma- depending on the severity of the disease surgery, cemotherapy anfd radiotherapy can be used[17]. |