Cellulitis, preseptal and orbital

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Aetiology

Infections of the periorbital and orbital tissues range in severity, from relatively minor to potentially life-threatening. These infections occur most commonly in children under the age of 10 years (incidence 1.6 per 100,000 to 6 per 100,000 in children under the age of 18 years, and 0.6 per 100,000 to 2.4 per 100,000 in adults)

Preseptal cellulitis

  • infection of tissues lying anterior to the orbital septum (therefore not an orbital condition)
  • in young children, high risk of extension into the orbit (orbital septum is less well-developed in young children)

Orbital cellulitis

  • infection of tissues lying posterior to the orbital septum (within the orbit)
  • severe sight and life-threatening emergency

Clinical differentiation between preseptal and orbital cellulitis is often difficult, particularly in children. For both conditions, the usual causative organisms are Staphylococcus (including MRSA) and Streptococcus species. In older children and adults infections may be polymicrobial with aerobic and anaerobic bacteria.

Predisposing factors

Haemophilus influenzae type b (Hib) vaccination against meningitis has significantly reduced the risk of pre-septal and orbital cellulitis in children

Preseptal cellulitis:

  • insect bite
  • trauma, sharp or blunt, around eye
  • dacryocystitis
  • hordeolum
  • impetigo (skin infection)
  • upper respiratory tract or middle ear infection
  • recent surgery around eye

Orbital cellulitis:

  • acute or chronic sinusitis (most cases)
    • secondary to ethmoidal sinus infection in children under 6
    • secondary to ethmoidal, maxillary or frontal sinusitis in children over 7
    • frontal sinus infection more common in adults
  • trauma including orbital fracture or penetrating foreign body
  • dacryocystitis
  • preseptal cellulitis
  • dental abscess
  • immunocompromise, for example in long-term steroid use
  • diabetes

Symptoms of cellulitis

Preseptal cellulitis:

  • acute onset of swelling, redness and tenderness of lids
  • fever
  • malaise
  • irritability in children

Orbital cellulitis:

  • sudden onset of unilateral swelling of conjunctiva and lids that may be painful
  • pain on ocular movement
  • blurred vision
  • diplopia
  • fever
  • severe malaise

Signs of cellulitis

Preseptal cellulitis:

  • eyelid redness (can extend beyond orbital rim)
  • lid oedema, warmth, tenderness
  • ptosis
  • pyrexia (fever greater than 38°C, normal temperature ranges from 36-37.5°C)

Orbital cellulitis:

  • severe unilateral eyelid redness and oedema (may extend to cheek and forehead)
  • ptosis
  • proptosis
  • restriction of extraocular motility
  • pain with eye movement
  • visual acuity may be reduced
  • impaired colour vision
  • pupil reactions may be abnormal (RAPD)
  • pyrexia
  • raised IOP (due to increased venous congestion)

Distinguishing between preseptal cellulitis and orbital cellulitis can be difficult based on clinical observations alone (especially in children) although the following table may be helpful for differential diagnosis. N.B. not all signs need to be present for a diagnosis of orbital cellulitis:

FeaturePreseptal cellulitisOrbital cellulitis
ProptosisAbsentPresent
Ocular motilityNormalPainful, restricted
Visual acuityNormalReduced in severe cases
Colour visionNormalReduced in severe cases
RAPDAbsentPresent in severe cases

(Modified from a table in Denniston AKO and Murray PI: Oxford Handbook of Ophthalmology, 4th edition, OUP 2018) 

Contrast-enhanced CT scanning should be performed in all patients with symptoms and signs suggestive of orbital cellulitis

Differential diagnosis

Preseptal cellulitis:

Orbital cellulitis:

  • cavernous sinus thrombosis (and can occur as complication in 1% of cases)
  • mucormycosis (fungal infection)
  • sarcoidosis
  • dysthyroid exophthalmos
  • neoplasia with inflammation
  • retinoblastoma

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere 

GRADE* Level of evidence and strength of recommendation always relates to the statement(s) immediately above

Non pharmacological 

None

Pharmacological   

In all children and in adults with orbital cellulitis: none

In adults with preseptal cellulitis, begin systemic treatment with oral antibiotics with broad spectrum of activity (e.g. Flucloxacillin or Co-Amoxiclav). Use alternative antibiotic e.g. Clindamycin in the case of penicillin allergy.

GRADE* level of evidence low, strength of recommendation strong

Management category

Orbital cellulitis in adults and preseptal or orbital cellulitis in children:
A1: emergency (same day) referral to ophthalmologist or A&E Department, no intervention

In adults with preseptal cellulitis:
B3: begin treatment with systemic antibiotic (see above). Requires close monitoring, if no improvement within 24-48 hours or symptoms worsen then refer as emergency (same day)

Possible management by ophthalmologist

Management of orbital infections typically involves a multi-disciplinary approach (ophthalmology, ENT, paediatrics)


Preseptal cellulitis:

  • confirmation of diagnosis
  • CT scan (orbits and sinuses)
  • children may require admission to hospital for observation
  • systemic antibiotics (oral and/or parenteral)

Orbital cellulitis:

  • confirmation of diagnosis
  • CT scan (orbits and sinuses)
  • blood tests (including ESR and CRP), possibly including microbial culture
  • admission to hospital
  • systemic antibiotics (intravenous) ± systemic steroid
  • drainage of orbital abscess and microbiological culture of fluid
  • co-management with ENT and paediatric specialist colleagues

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation (see www.gradingworkinggroup.org)
 

Sources of evidence

Ambati BK, Ambati J, Azar N, Stratton L, Schmidt EV. Periorbital and orbital cellulitis before and after the advent of Haemophilus influenzae type B vaccination. Ophthalmology. 2000;107(8):1450-3.

Amin N, Syed I, Osborne S. Assessment and management of orbital cellulitis. Br J Hosp Med (Lond). 2016;77(4):216-20

Baring DE, Hilmi OJ. An evidence based review of periorbital cellulitis. Clin Otolaryngol. 2011;36(1):57-64

BMJ Best Practice. Periorbital and orbital cellulitis. 2020. (subscription required)

Georgakopoulos CD, Eliopoulou MI, Stasinos S, Exarchou A, Pharmakakis N, Varvarigou A. Periorbital and orbital cellulitis: a 10-year review of hospitalized children. Eur J Ophthalmol. 2010;20(6):1066-72

Gordon AA, Phelps PO. Management of preseptal and orbital cellulitis for the primary care physician. Dis Mon. 2020;66(10):101044

Kornelsen E, Mahant S, Parkin P, Ren LY, Reginald YA, Shah SS, Gill PJ. Corticosteroids for periorbital and orbital cellulitis. Cochrane Database Syst Rev. 2021;4(4):CD013535

Tsirouki T, Dastiridou AI, Ibánez Flores N, Cerpa JC, Moschos MM, Brazitikos P, Androudi S. Orbital cellulitis. Surv Ophthalmol. 2018;63(4):534-553

Upile NS, Munir N, Leong SC, Swift AC. Who should manage acute periorbital cellulitis in children? Int J Pediatr Otorhinolaryngol. 2012;76(8):1073-7

Williams KJ, Allen RC. Paediatric orbital and periorbital infections. Curr Opin Ophthalmol. 2019;30(5):349-355

Yadalla D, Jayagayathri R, Padmanaban K, Ramasamy R, Rammohan R, Nisar SP, Rangarajan V, Menon V. Bacterial orbital cellulitis - A review. Indian J Ophthalmol. 2023;71(7):2687-2693.

Summary

What is Preseptal and orbital cellulitis?

Cellulitis means inflammation of the soft tissues, often due to infection. Preseptal and orbital cellulitis are infections of the soft tissues in the socket that surrounds the eye, usually caused by common bacteria. They may follow a cold, sinusitis, an infection of the eyelid such as a stye, an infection of the tear drainage channels, or injury or recent surgery near the eye. It is important to try to distinguish between these two forms of cellulitis. Preseptal cellulitis is usually mild, except in young children, but orbital cellulitis can result in generalised infection which can be a life-threatening emergency. 

How is Preseptal and orbital cellulitis managed?

All cases of suspected orbital cellulitis need emergency (same day) referral to the ophthalmologist or to an Accident and Emergency Department. Most will need to be admitted to hospital for tests and antibiotic treatment and a number of different specialists may be involved: ophthalmologists, ear, nose and throat specialists, and paediatricians (children’s doctors).

Cellulitis, preseptal and orbital
Version 14
Date of search 30.07.23
Date of revision 26.10.23
Date of publication 23.01.24
Date for review 29.07.25
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