Cellulitis, preseptal and orbital

The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.

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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
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

For both conditions, the usual causative organisms are Staphylococcus, Streptococcus and Haemophilus species

 

Predisposing factors 

Preseptal cellulitis:

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

Orbital cellulitis:

  • acute sinusitis (especially ethmoid sinusitis)
  • trauma including orbital fracture
  • dacryocystitis
  • preseptal cellulitis
  • dental abscess 

 

Symptoms

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 

Preseptal cellulitis:

  • erythema of skin (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:

  • proptosis
  • restriction of extraocular motility
  • pain with eye movement
  • visual acuity may be reduced
  • 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, 3rd edition, OUP 2014) 

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)
  • acute blepharitis
  • viral conjunctivitis with eyelid swelling
  • allergic conjunctivitis with eyelid swelling
  • angioneurotic oedema (if bilateral): could indicate severe systemic allergic reaction, e.g. in peanut allergy
  • insect bite or sting (if unilateral): look for skin lesion(s)

Orbital cellulitis:

  • cavernous sinus thrombosis
  • mucormycosis (fungal infection)
  • sarcoidosis
  • dysthyroid exophthalmos
  • neoplasia with inflammation

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   

None

Management category

Preseptal and orbital cellulitis:
A1: emergency (same day) referral to ophthalmologist or A&E Department, no intervention

Possible management by ophthalmologist 

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

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

Orbital cellulitis:

  • confirmation of diagnosis
  • CT scan
  • blood tests, possibly including microbial culture
  • admission to hospital
  • systemic antibiotics (intravenous)
  • 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 (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

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

Nageswaran S, Woods CR, Benjamin DK Jr, Givner LB, Shetty AK. Orbital cellulitis in children. Pediatr Infect Dis J. 2006;25(8):695-9

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

 

Lay summary

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. 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 11
Date of search 21.04.17
Date of revision 20.09.17
Date of publication 05.12.17
Date for review 20.05.19
© College of Optometrists 

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