Periorbital and Orbital Cellulitis
Adaobi Okobi, M.D.
Pediatrics Chief Resident
St. Barnabas Hospital
Objectives
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Differentiate between periorbital
and orbital cellulitis based on
history and physical exam
Discuss the causes and treatments
of periorbital and orbital cellulitis
Review the indications for imaging
and ophthalmology consultation for
eyelid swelling
Recognize the complications of
periorbital and orbital cellulitis
Simplified anatomy of the eye, paranasal sinuses, and venous drainage
Hauser, A. et al. Pediatrics in Review 2010;31:242-249
Copyright ©2010 American Academy of Pediatrics
Pathogenesis
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Sinusitis
Extension of external ocular infection (ie
hordeolum, dacryocystitis/dacroadenitis)
Dental abscess
Superficial break in the skin (ie infected
bug bite, acne, eczema, periocular
surgery or direct penetrating trauma)
Hematogenous spread
Organisms
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Haemophilus influenza type b
(before Hib vaccine in 1985)
Staphylococcus aureus (including
MRSA)
S. epidermidis
Streptococcus pyogenes
History
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Past sinus disease?
Past dental disease?
Previous eye surgery?
History of trauma?
Physical Exam
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Observe for degree of ocular
swelling
Assess extraocular movement
Evaluate for foreign body
Assess visual acuity
Clinical Signs and Symptoms
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Unilateral
erythema of eyelid
Swelling of eyelid
Warmth of eyelid
Tenderness of
eyelid
Blurred vision
Ophthalmoplegia
Proptosis
Chemosis
Imaging: Indications
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Eyelid edema that makes a complete
examination impossible
Presence of CNS involvement (ie seizures,
focal neurologic deficits, or altered mental
status)
Deteriorated visual acuity or color vision
Proptosis
Ophthalmoplegia
Clinical worsening or no improvement
after 24-48 hours
A 15-month-old girl who has periorbital cellulitis and fever following infection of an insect
bite to her lower right eyelid despite treatment with several days of cephalexin
Hauser, A. et al. Pediatrics in Review 2010;31:242-249
Copyright ©2010 American Academy of Pediatrics
An 11-year-old boy who has pan-sinusitis and left orbital cellulitis and presented with
fever, severe left eye pain, proptosis, chemosis, and limitation of extraocular movements
Hauser, A. et al. Pediatrics in Review 2010;31:242-249
Copyright ©2010 American Academy of Pediatrics
Differential Diagnosis
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Allergic reaction
Edema from hypoproteinemia
Orbital wall infarction
Subperiosteal hematoma
Orbital pseudotumor
Orbital myositis
Retinoblastoma
Metastatic carcinoma
Exophthalmos secondary to thyroid
dysfunction
Admission Criteria
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Patients with orbital
cellulitis presenting
with:
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Eyelid edema
Diplopia
Reduced visual acuity
Abnormal light
reflexes
Ophthalmoplegia
Proptosis
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Appears toxic
Eye exam is unable to
be completely
performed
Signs of CNS
involvement:
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Lethargy
Vomiting
Seizures
Headache
Cranial nerve deficit
Management
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Depends on the patient’s appearance,
ability to take oral medications,
compliance and clinical progression of the
disease
Empiric antibiotics should cover
Staphylococcus and Streptococcus
species, particularly MRSA
Treat for 7-10 days for periorbital cellulitis
Treat for 10-14 days for orbital cellulitis
If no improvement in 24-48 hours
consider consulting Infectious Disease,
ophthalmology, ENT and/or neurosurgery
Management
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Obtain blood culture in younger patients
or those that appear systemically ill
Culture ocular discharge
Obtain orbital, epidural absces or sinus
fluid if patient requires surgery
Include a sepsis evaluation if the patient
appears toxic or has neurologic
involvement
Complications
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Local abscess formation
Orbital cellulitis
Intracranial extension of infection (eg
subdural empyema, intracerebral abscess,
extradural abscess and meningitis)
Cavernous venous sinus thrombosis
Septic emboli of the optic nerve
Optic nerve ischemia (due to
compression) may result in visual loss
Summary
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Orbital cellulitis is an emergency that requires prompt
diagnosis and evaluation by ophthalmology
Periorbital cellulitis and orbital cellulitis have distinct
differences that can be elicited by careful history and
physical examination
If the physical exam cannot be fully completed for
any reason, radiologic imaging is required
Patients with systemic illness or evidence of orbital
cellulitis or neurologic involvement require inpatient
admission
Improvement should occur within 24-48 hours with
antibiotics
Questions
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A 6 year old child is brought to the emergency department by
his parents because of upper respiratory tract symptoms, a
progressively swollen left eye, and altered mental status. He
has been otherwise healthy and is fully immunized. Upon
examination, he is difficult to arouse. Local signs include a
markedly swollen left eye with proptosis. Eye movements are
difficult to assess because of the boy’s poor neurologic status.
He is febrile, but hemodynamically stable. The most likely
pathogenesis is:
A. Acute bacterial meningitis, with secondary infection of the
left orbit
B. Bacteremia causing both ocular and intracranial illness
C. Head trauma, with ocular and intraocular manifestations
D. Intracranial mass causing ocular and neurologic
manifestations
E. Orbital cellulitis, with the neurologic complication of
bacterial meningitis
Questions
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A father calls your office to report that his 2 year old
daughter has had nasal congestion and fever for the past 2
days. She received a nonprescription medication this
morning, and today her right eye is “swollen shut”. When she
arrives in your office, she is febrile but nontoxic. Her right
eyelids are swollen and erythematous. It is nearly impossible
to determine whether her extraocular movements are normal,
but she exhibits increased tearing of the affected eye. Of the
following, the most reasonable diagnosis and plan of
treatment are:
A. Allergic reaction and trial of antihistamine at home
B. Periorbital cellulitis and IV antibiotics and CT scan of the
orbits
C. Periorbital cellulitis and ophthalmology consultation and IV
antibiotics
D. Periorbital cellulitis and oral antibiotics at home
E. Reactive periorbital swelling from sinusitis and nasal
decongestant at home
References
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Hauser, A and Fogarasi, S.
Periorbital and Orbital Cellulitis.
Pediatrics in Review. 2010;31:242249