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Cellulitis, Periorbital

Basics

  • Infection limited to skin and subcutaneous tissue anterior to orbital septum.
  • Synonym: Preseptal cellulitis.
  • Does not involve globe, orbital fat, or muscles.

Epidemiology

  • More common in children; mean age ~21 months.
  • Occurs 3x more frequently than orbital cellulitis.
  • Incidence peaks in winter (linked to sinusitis).

Etiology and Pathophysiology

  • Infection spreads contiguously from facial soft tissues.
  • Common sources: sinusitis (via lamina papyracea), local trauma, insect/animal bites, foreign bodies, dental abscess.
  • Common pathogens:
  • Staphylococcus aureus (mostly MSSA; MRSA increasing)
  • Staphylococcus epidermidis
  • Streptococcus pyogenes
  • Atypical organisms include Acinetobacter, Nocardia, Bacillus anthracis, Pseudomonas aeruginosa, Neisseria gonorrhoeae, Proteus, Pasteurella multocida, Mycobacterium tuberculosis, Trichophyton spp.
  • Haemophilus influenzae decreased after vaccination but considered in unimmunized.

Risk Factors

  • Upper respiratory infection, sinusitis
  • Conjunctivitis, blepharitis
  • Skin trauma or puncture near eyes
  • Insect bites
  • Bacteremia

Prevention

  • Avoid periocular trauma.
  • Avoid swimming with skin abrasions.
  • Routine vaccinations, especially Hib and pneumococcus.

Diagnosis

History

  • Eyelid swelling, erythema, warmth, tenderness.
  • Normal vision and ocular motility usually preserved.
  • Fever may be absent.
  • Pain on eye movement, chemosis, and proptosis suggest orbital cellulitis.

Physical Exam

  • Vital signs and general appearance.
  • Inspect eyelids for erythema, swelling, tenderness without orbital congestion.
  • Look for skin breakdown, vesicles (herpetic infection).
  • Palpate sinuses; check oral cavity for dental abscess.
  • Assess ocular motility and visual acuity.

Differential Diagnosis

  • Orbital cellulitis (distinguished by pain with eye movement, proptosis, diplopia, vision loss).
  • Abscess
  • Dacryocystitis
  • Hordeolum (stye)
  • Allergic inflammation
  • Trauma
  • Orbital pseudotumor, orbital myositis
  • Tumors: rhabdomyosarcoma, retinoblastoma, lymphoma, leukemia

Diagnostic Tests

  • CBC with differential.
  • Blood cultures (low yield).
  • Wound culture if purulence present.
  • Imaging if suspicion of orbital cellulitis or failure to improve after 24-48h oral antibiotics:
  • Contrast-enhanced CT orbit and sinuses (2 mm sections, axial and coronal views).
  • CT sign of orbital cellulitis: medial rectus bulging.
  • Hospitalized febrile children <15 months may require blood cultures and lumbar puncture.

Treatment

Medication

  • Oral antibiotics targeting Staphylococcus and Streptococcus.
  • Consider local MRSA prevalence for coverage.
  • First-line for uncomplicated posttraumatic cases:
  • Cephalexin 500 mg PO q6h or dicloxacillin 500 mg PO q6h.
  • If MRSA suspected: clindamycin 300 mg PO TID, doxycycline 100 mg PO BID, or TMP-SMX.
  • Sinusitis extension:
  • Amoxicillin-clavulanate 875/125 mg PO BID.
  • 3rd-gen cephalosporins (e.g., cefdinir 300 mg PO BID).
  • Dental abscess:
  • Amoxicillin-clavulanate or clindamycin.
  • Bacteremic cellulitis:
  • Ceftriaxone 1 g IV daily plus vancomycin or clindamycin IV.
  • Duration: 10-14 days oral therapy.
  • Close follow-up daily until improvement.
  • Escalate to IV antibiotics if no improvement in 24 hours.

Surgery

  • Usually not needed unless abscess or compromise of critical structures.
  • Diplopia strongest predictor for surgery.

Admission

  • Outpatient management for stable mild cases in adults and children >1 year.
  • Hospitalize and give IV antibiotics if:
  • Systemic illness.
  • Children <1 year.
  • Unimmunized against S. pneumoniae or H. influenzae.
  • No improvement or deterioration within 24h oral antibiotics.
  • Suspicion of orbital cellulitis (eyelid swelling with vision changes, diplopia, proptosis).

Ongoing Care

  • Monitor for signs of orbital involvement (decreased vision, painful/limited eye movement).

Patient Education

  • Maintain skin hygiene.
  • Avoid trauma.
  • Report recurrent swelling/redness promptly.

Prognosis

  • Good with timely treatment.
  • Recurrent periorbital cellulitis if ≥3 episodes/year separated by at least 1 month.
  • Differentiate from antibiotic resistance or treatment failure.

Complications

  • Progression to orbital cellulitis.
  • Orbital abscess.
  • Vision loss.
  • Cavernous sinus thrombosis.
  • Osteomyelitis.

Clinical Pearls

  • Periorbital and orbital cellulitis mainly affect children.
  • CT scan is key to distinguish preseptal from orbital cellulitis.
  • Orbital cellulitis presents with fever, pain on eye movement, diplopia, proptosis.
  • Early imaging and specialist consultation needed if orbital cellulitis suspected.

References:

  1. Baring DEC, Hilmi OJ. An evidence based review of periorbital cellulitis. Clin Otolaryngol. 2011;36(1):57-64.
  2. Williams KJ, Allen RC. Paediatric orbital and periorbital infections. Curr Opin Ophthalmol. 2019;30(5):349-355.