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: 

(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

None

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

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