Surgeons face choices in pediatric orbital cellulitis

Reviewed by César Briceño, MD

Philadelphia-Clinicians treating pediatric orbital cellulitis must carefully balance the risks and benefits of steroids, according to César Briceño, MD.

In orbital cellulitis, one of the biggest dangers is from swelling within the eye socket, said Dr. Briceño, assistant professor of ophthalmology, University of Pennsylvania, Philadelphia.

“There is not a lot of space there, and you can have impingement of important structures, leading to vision loss,” he said.

The swelling in the orbit can be exacerbated by pockets of pus, leading to increased pressure, he said, and antibiotics alone may not reduce the swelling rapidly enough.

Steroids reduce the inflammation, but might hamper the immune response.

“On a theoretical basis you could prolong the infection by treating someone with steroids,” he said. “This is where the medicine is really an art. There are not that many standard criteria to make that decision.”

There have not been adequate clinical trials to provide clear guidance, he said, but noted that the research so far favors careful steroid use. He cited Pushker et al. (Am J Ophthalmol. 2013;156:178-183) and Yen et al. (Ophthal Plast Reconstr Surg. 2005;21:363-366).

In addition to reducing compression, steroids can decrease fibroblast proliferation and thus the risk of scarring that can lead to long-term sequelae, he said.

“When used judiciously steroids can be a way to reduce morbidity in the child, and also reduce costs,” he said. “That’s quite relevant in our current regulatory climate.”

Making treatment decision

Making treatment decision

The first step in deciding on how to treat these patients is to scan the orbit with computed tomography, Dr. Briceño said.

This can reveal a subperiosteal abscess inside the orbit and show where there is swelling.

“A small pocket can be managed with medicine,” he said. “If it’s large, we usually send the child to surgery.”

He prefers to prescribe steroids only in immunocompetent patients, and takes into consideration comorbidities. For example, if a patient also has a dental infection, he would consult with the oral and maxillofacial surgeon before prescribing steroids.

He typically starts with 1 mg per kilogram of body weight per day of prednisone or the intravenous equivalent.

“That’s my starting dose,” he said. “I taper according to clinical response.”

He prefers not to discharge patients who are still on steroids because if a problem emerges it may be difficult to re-admit them.

Surgery as an option

Surgery as an option

Several factors might favor surgery, he said, citing a report by Garcia et al. (Ophthalmology. 2000;107:1454-1458). These include an age of 9 or older, presence of frontal sinusitis, nonmedial location of the pocket, suspicion of an anaerobic pocket, a recurrent pocket, evidence of chronic sinusitis, compromise of the optic nerve or retina, and an infection of dental origin.

“If the child already has signs of vision loss, I’m not going to wait to operate,” he said. “The source of the infection has a lot to do with this. If they have a particularly dangerous bacterium, or if they also have a dental infection, I would collaborate with my oral and maxillofacial colleagues.”

When a patient needs surgery, the approach depends on the location of the abscess. The Lynch incision is done between the nasal bridge and eyebrow.

It provides “fabulous access to the medial aspect of the orbit,” said Dr. Briceño. “But it can have some esthetic drawbacks because of the visibility of the scar.”

So his personal preference is to take the transcaruncular approach to the medial orbit, and to access the roof, floor or lateral wall of the orbit through a lateral eyelid crease. These approaches provide good access with minimal esthetic consequences, he said.

When the incision is made in the lid crease, it tends to heal in a way that is camouflaged by the presence of the lid crease, he said.

Multiple approaches

Multiple approaches

Sometimes he must use multiple approaches because puss has collected in multiple locations.

Children who also have sinus infections may be under treatment by an otolaryngologist who can access the orbit endoscopically. Then there is complete absence of an external scar.

“So when one has access to such a collaboration, that is the preferred method for accessing medial abscesses,” Dr. Briceño said. “But it’s endoscopically difficult to access the other areas of the orbit, whether the floor or the roof or the lateral wall.”

Often draining abscesses requires placement of a drain. Dr. Briceño likes to make the drain incision separate from the access incision because he finds that this also yields better esthetic outcomes.

César Briceño, MD

E: cesar.briceno@gmail.com

This article was adapted from Dr. Briceño’s presentation at the 2015 meeting of the American Academy of Ophthalmology. He did not indicate any proprietary interest in the subject matter.