Peri-orbital and orbital cellulitis

Last reviewed: May 2019

Last updated: March 2018

Summary

Peri-orbital cellulitis is an infectious process occurring in the eyelid tissues superficial to (anterior to or above) the orbital septum. It is usually due to superficial tissue injury (e.g., insect bite or chalazion).

Orbital cellulitis is an infectious process affecting the muscles and fat within the orbit, posterior or deep to the orbital septum, not involving the globe. It is usually due to underlying bacterial sinusitis.

Peri-orbital cellulitis is of concern in children because it may be secondary to occult underlying bacterial sinusitis or, rarely, due to bacteraemic spread from a primary infection (e.g., pneumonia), and may rapidly progress to orbital cellulitis in children.

Complications include sub-periosteal abscess, cavernous sinus thrombosis, intracranial abscess, and subsequent loss of vision and/or death.

Definition

Peri-orbital (also known as pre-septal) cellulitis is inflammation and infection of the superficial eyelid, usually from a superficial source. The inflammation remains confined to the soft tissue layers superficial to the orbital septum and ocular function remains intact.

Orbital cellulitis is an infection within the orbital soft tissues with associated ocular dysfunction and is usually due to underlying bacterial sinusitis. Orbital cellulitis is a far more serious condition and warrants hospital admission. It has much higher morbidity than peri-orbital cellulitis, and warrants urgent imaging and surgical evaluation by oculoplastic as well as a head-and-neck consultant.

History and exam

Key diagnostic factors

presence of risk factors
recent sinus infection
recent eyelid injury
redness and swelling of eye
ocular pain
decreased vision
proptosis
eyelid oedema
insect bite on eyelid
stye or chalazion
ear or facial infection
ophthalmoplegia and diplopia

Full details

Other diagnostic factors

orbital trauma
skin infection
chemosis
tenderness around eye
fever
eyelid erythema
elevated intra-ocular pressure
headache
malaise
previous dental infection or dental work
orbital fracture
foreign body in eye or orbit
drowsiness
nausea/vomiting
nasal discharge

Full details

Risk factors

sinusitis
young age
male sex
lack of Hib vaccine in children

Full details

Diagnostic investigations

1st investigations to order

clinical examination
CT sinus and orbits with contrast
WBC count

Full details

Investigations to consider

blood culture
microbiology swab (conjunctiva, nasopharynx, external wounds)
MRI head and orbits with contrast
lumbar puncture

Full details

Treatment algorithm

ACUTE

peri-orbital cellulitis: causative organism not identified

peri-orbital cellulitis: causative organism identified

orbital cellulitis: causative organism not identified

orbital cellulitis: causative organism identified

Contributors

Authors VIEW ALL 

H. Jane Kim, MD

Oculofacial Plastic and Reconstructive Surgery

Department of Ophthalmology

Kaiser Permanente Medical Group

Union City

Disclosures

HJK declares that she has no competing interests.

Robert Kersten, MD

Professor of Clinical Ophthalmology

Department of Ophthalmology

University of California San Francisco

San Francisco

Disclosures

RK declares that he has no competing interests.

Acknowledgements

Dr H. Jane Kim and Dr Robert Kersten would like to gratefully acknowledge Dr Sandra Lora Cremers and Dr Sarosh Janjua, previous contributors to this monograph. SLC and SJ declare that they have no competing interests.

Peer reviewers VIEW ALL 

David M. Ozog, MD

Director of Cosmetic Dermatology

Department of Dermatology

Cosmetic and Procedural Dermatology

Henry Ford Health System

Detroit

Disclosures

DMO declares that he has no competing interests.

I-Hui (Elaine) Wu, MD

Resident

Wilmer Eye Institute

Baltimore

Disclosures

IW declares that she has no competing interests.

Cristine Radojicic, MD

Staff Physician

Cleveland Clinic

Cleveland

Disclosures

CR declares that she has no competing interests.

Jonathan Smith, MD

Specialist Registrar in Ophthalmology

Royal Victoria Infirmary

Newcastle

Disclosures

JS declares that he has no competing interests.

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Peri-orbital and orbital cellulitis

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

peri-orbital cellulitis: causative organism not identified

peri-orbital cellulitis: causative organism identified

orbital cellulitis: causative organism not identified

orbital cellulitis: causative organism identified

Contributors

Authors VIEW ALL 

H. Jane Kim, MD

Disclosures

Robert Kersten, MD

Disclosures

Acknowledgements

Peer reviewers VIEW ALL 

David M. Ozog, MD

Disclosures

I-Hui (Elaine) Wu, MD

Disclosures

Cristine Radojicic, MD

Disclosures

Jonathan Smith, MD

Disclosures

Differentials

Guidelines

Patient leaflets

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