- Abnormalities of the Pupil
- Atopic Keratoconjunctivitis (AKC)
- Basal cell carcinoma (BCC) (periocular)
- Blepharitis (Lid Margin Disease)
- CL-associated Papillary Conjunctivitis (CLAPC), Giant Papillary Conjunctivitis (GPC)
- Cellulitis, preseptal and orbital
- Chalazion (Meibomian cyst)
- Concretions
- Conjunctival pigmented lesions
- Conjunctival scarring
- Conjunctivitis (Acute Allergic)
- Conjunctivitis (bacterial)
- Conjunctivitis (viral, non-herpetic)
- Conjunctivitis (seasonal & perennial allergic)
- Conjunctivitis, Chlamydial
- Conjunctivitis medicamentosa (also Dermatoconjunctivitis medicamentosa)
- Corneal (or other superficial ocular) foreign body
- Corneal Transplant Rejection
- Corneal abrasion
- Corneal hydrops
- Dacryocystitis (acute)
- Dacryocystitis (chronic)
- Dry Eye (Keratoconjunctivitis Sicca, KCS)
- Ectropion
- Endophthalmitis (post-operative) (Exogenous endophthalmitis)
- Entropion
- Episcleritis
- Facial palsy (Bell's Palsy)
- Fuchs Endothelial Corneal Dystrophy (FECD)
- Glaucoma (chronic open angle) (COAG)
- Herpes Simplex Keratitis (HSK)
- Herpes Zoster Ophthalmicus (HZO)
- Hordeolum
- Keratitis (marginal)
- Keratitis, CL-associated infiltrative
- Microbial keratitis (Acanthamoeba sp.)
- Microbial keratitis (bacterial, fungal)
- Molluscum contagiosum
- Nasolacrimal duct obstruction (nasolacrimal drainage dysfunction)
- Ocular hypertension (OHT)
- Ocular rosacea
- Ophthalmia neonatorum
- Photokeratitis (Ultraviolet [UV] burn, Arc eye, Snow Blindness)
- Phthiriasis (pediculosis ciliaris)
- Pigmented fundus lesions
- Pinguecula
- Post-operative suture breakage
- Primary Angle Closure / Primary Angle Closure Glaucoma (PAC / PACG)
- Pterygium
- Recurrent corneal epithelial erosion syndrome
- Retinal Vein Occlusion
- Scleritis
- Steroid-related Ocular Hypertension and Glaucoma
- Sub-conjunctival haemorrhage
- Sub-tarsal foreign body (STFB)
- Trauma (blunt)
- Trauma (chemical)
- Trauma (penetrating)
- Trichiasis
- Uveitis (anterior)
- Vernal Keratoconjunctivitis
- Vitreomacular Traction and Macular Hole
- How to use the Clinical Management Guidelines
Cellulitis, preseptal and orbital

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Contents
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
- bacterial 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 cellulitis
- bacterial 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, Streptococcus (including MRSA), and Haemophilus species
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
- dacryocystitis
- hordeolum
- impetigo (skin infection)
- trauma, sharp or blunt, around eye
- recent surgery around eye
- upper respiratory tract infection
Orbital cellulitis:
- acute sinusitis (most cases)
- secondary to ethmoidal sinus infection in children under 6
- secondary to ethmoidal, maxillary or frontal sinusitis in children over 7
- trauma including orbital fracture
- 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 and reduced visual acuity
- 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 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
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:
Feature | Preseptal cellulitis | Orbital cellulitis |
Proptosis | Absent | present |
Ocular motility | Normal | painful, restricted |
Visual acuity | Normal | reduced in severe cases |
Colour vision | Normal | reduced in severe cases |
RAPD | Normal | present 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
- hordeolum (external or internal)
- dacryocystitis (acute)
- acute blepharitis
- viral conjunctivitis with eyelid swelling
- acute allergic conjunctivitis with eyelid swelling
- angioneurotic oedema (if bilateral): could indicate severe systemic allergic reaction, e.g. in peanut allergy
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 Flucloxacillin or Co-Amoxiclav
GRADE* level of evidence low, strength of recommendation strong
Management category
Preseptal and orbital cellulitis in children, and orbital cellulitis in adults:
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)
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, 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
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
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 lifethreatening emergency.
How is Preseptal and orbital cellulitis managed?
All cases need emergency 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 13
Date of search 27.07.21
Date of revision 25.11.21
Date of publication 26.01.22
Date for review 24.07.23
© College of Optometrists
- Abnormalities of the Pupil
- Atopic Keratoconjunctivitis (AKC)
- Basal cell carcinoma (BCC) (periocular)
- Blepharitis (Lid Margin Disease)
- CL-associated Papillary Conjunctivitis (CLAPC), Giant Papillary Conjunctivitis (GPC)
- Cellulitis, preseptal and orbital
- Chalazion (Meibomian cyst)
- Concretions
- Conjunctival pigmented lesions
- Conjunctival scarring
- Conjunctivitis (Acute Allergic)
- Conjunctivitis (bacterial)
- Conjunctivitis (viral, non-herpetic)
- Conjunctivitis (seasonal & perennial allergic)
- Conjunctivitis, Chlamydial
- Conjunctivitis medicamentosa (also Dermatoconjunctivitis medicamentosa)
- Corneal (or other superficial ocular) foreign body
- Corneal Transplant Rejection
- Corneal abrasion
- Corneal hydrops
- Dacryocystitis (acute)
- Dacryocystitis (chronic)
- Dry Eye (Keratoconjunctivitis Sicca, KCS)
- Ectropion
- Endophthalmitis (post-operative) (Exogenous endophthalmitis)
- Entropion
- Episcleritis
- Facial palsy (Bell's Palsy)
- Fuchs Endothelial Corneal Dystrophy (FECD)
- Glaucoma (chronic open angle) (COAG)
- Herpes Simplex Keratitis (HSK)
- Herpes Zoster Ophthalmicus (HZO)
- Hordeolum
- Keratitis (marginal)
- Keratitis, CL-associated infiltrative
- Microbial keratitis (Acanthamoeba sp.)
- Microbial keratitis (bacterial, fungal)
- Molluscum contagiosum
- Nasolacrimal duct obstruction (nasolacrimal drainage dysfunction)
- Ocular hypertension (OHT)
- Ocular rosacea
- Ophthalmia neonatorum
- Photokeratitis (Ultraviolet [UV] burn, Arc eye, Snow Blindness)
- Phthiriasis (pediculosis ciliaris)
- Pigmented fundus lesions
- Pinguecula
- Post-operative suture breakage
- Primary Angle Closure / Primary Angle Closure Glaucoma (PAC / PACG)
- Pterygium
- Recurrent corneal epithelial erosion syndrome
- Retinal Vein Occlusion
- Scleritis
- Steroid-related Ocular Hypertension and Glaucoma
- Sub-conjunctival haemorrhage
- Sub-tarsal foreign body (STFB)
- Trauma (blunt)
- Trauma (chemical)
- Trauma (penetrating)
- Trichiasis
- Uveitis (anterior)
- Vernal Keratoconjunctivitis
- Vitreomacular Traction and Macular Hole
- How to use the Clinical Management Guidelines