What is the management approach for ptosis (drooping of the eyelid) following peri-orbital cellulitis (infection around the eye)?

Management of Ptosis Following Periorbital Cellulitis

Surgical correction of ptosis may be helpful in cases of ptosis following periorbital cellulitis, particularly when associated with giant fornix syndrome. 1

Understanding Ptosis After Periorbital Cellulitis

Ptosis (drooping of the eyelid) can occur as a complication following periorbital cellulitis. It's important to first understand the distinction between:

• Periorbital cellulitis: More common infection limited to the eyelids in the preseptal region (85% of cases) 2
• Orbital cellulitis: More severe infection posterior to the orbital septum (15% of cases) 2

Evaluation of Post-Infectious Ptosis

Before initiating treatment, a thorough evaluation should include:

• Assessment of ptosis severity and impact on vision
• Evaluation for residual infection or inflammation
• Examination for associated complications such as:
  • Subconjunctival fibrosis
  • Mechanical restrictions
  • Persistent conjunctival scarring

Management Algorithm

1. Ensure Complete Resolution of Infection

• Confirm that the periorbital cellulitis has fully resolved
• Verify no signs of active infection remain
• If infection persists, complete appropriate antibiotic course:
  • For simple periorbital cellulitis: oral antibiotics (dicloxacillin, cephalexin, clindamycin, or amoxicillin-clavulanate) 3
  • For orbital cellulitis: intravenous antibiotics (often combination therapy) 3

2. Conservative Management (Initial Approach)

• Observation for 4-6 months to allow for spontaneous improvement
• Lubricating eye drops to prevent corneal exposure issues
• Treatment of any associated conditions:
  • Aqueous tear deficiency
  • Meibomian gland dysfunction

3. Surgical Intervention

Surgical correction is indicated when:

• Ptosis persists after resolution of infection
• Vision is affected
• Cosmetic concerns are significant
• Associated with giant fornix syndrome 1

The surgical approach should be determined based on:

• Severity of ptosis
• Levator muscle function
• Presence of associated scarring or fibrosis

Special Considerations

Giant Fornix Syndrome

In cases where ptosis is associated with giant fornix syndrome:

• Obtain conjunctival cultures (typically positive for Staphylococcus aureus)
• Consider prolonged systemic anti-staphylococcal antibiotics
• Use intensive topical antibiotics and corticosteroids
• Consider supratarsal injections of antibiotics and corticosteroids
• Irrigation and sweeping of the fornix with povidone-iodine solution may be beneficial
• Surgical correction of ptosis is specifically recommended 1

Potential Complications of Surgical Intervention

Be aware of possible complications following surgical correction of ptosis:

• Foreign body sensation
• Corneal abrasion
• Allergic reaction
• Delle (2.2%-18.9%, higher risk in reoperations) 1
• Subconjunctival hemorrhage
• Chemosis
• Conjunctival scarring
• Overcorrection or undercorrection
• Limitation of eye movements 1

Follow-up Care

• Regular follow-up visits based on severity of ptosis and treatment approach
• At follow-up visits, perform:
  • Interval history
  • Visual acuity measurement
  • Slit-lamp biomicroscopy 1
• Monitor for signs of recurrent infection
• Assess adequacy of ptosis correction

Conclusion

Management of ptosis following periorbital cellulitis requires a stepwise approach, beginning with ensuring complete resolution of infection, followed by observation for potential spontaneous improvement, and ultimately surgical correction when indicated. Surgical intervention is particularly beneficial in cases associated with giant fornix syndrome, where ptosis correction is specifically recommended as part of comprehensive management.