11/14/24, 10\:52 AM Orbital and Peri-orbital Cellulitis
Orbital and Peri-orbital Cellulitis
Key points ⚡
Succinct notes to superpower your revision
Orbital cellulitis\: infection of muscles and fat within the orbit, posterior to the orbital septum; more common in children;
serious sight-threatening condition; 11% have visual loss post-infection.
Aetiology\: local spreading from acute bacterial sinusitis, extension of peri-orbital cellulitis, haematogenous spread, trauma
(e.g., dog bite), contiguous spread from face/teeth.
Symptoms\: erythema/swelling around the eye, blurred vision, painful eye movements, change in colour vision, fever.
Examination\: nasal and oral cavity examination, eye/vision assessment (visual
re
Clinical
chemosis, altered colour vision.
Investigations\: FBC, CRP, lactate, blood cultures, conjunctiva/nasopharynx swabs; contrast-enhanced CT of
orbit/sinuses/brain, MR venogram if needed.
Management\: emergency referral to ophthalmology/ENT, IV antibiotics for 7-10 days, potential surgical drainage if abscess
detected on imaging.
Complications\: cavernous sinus thrombosis, visual loss, intracerebral abscess, meningitis, rare death.
Peri-orbital cellulitis\: infection in eyelid tissues anterior to orbital septum; more common and less severe than orbital
cellulitis.
Aetiology\: super
Symptoms\: pain, redness, swelling of eyelid, recent insect bites/styes, URTIs.
Clinical features\: eyelid redness, mild tenderness, swelling, fever; no signi
on eye movement, intact colour vision, no chemosis/proptosis.
Management\: emergency referral if suspicion of orbital cellulitis, systemically unwell, or not responding to treatment; oral
co-amoxiclav
Complications\: peri-orbital cellulitis can spread to orbital cellulitis.
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Introduction
Orbital and peri-orbital cellulitis re
septum.
Peri-orbital cellulitis refers to infection occurring anterior to the orbital septum (pre-septal) and orbital cellulitis refers to
infection occurring posterior to the orbital septum (post-septal).
The orbital septum is a membranous sheet that forms the anterior boundary of the orbit and separates the pre-septal and
post-septal spaces (Figure 1). The septum acts as a barrier to infection. It originates both superiorly and inferiorly from the
orbital periosteum. Superiorly, it is continuous with levator palpebrae superioris. Inferiorly, it is continuous with the inferior
tarsal plate.
1
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Figure 1. Right eye in sagittal section. Blue markings show contents of
the orbital septum.
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Orbital cellulitis
Orbital cellulitis involves infection of the muscle and fat within the orbit, posterior to the orbital septum.
It is more common in children, with the incidence reported to be 16-fold higher in children compared to adults.
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Di
Orbital cellulitis is a serious sight-threatening condition. Approximately 11% of patients will have visual loss following
orbital cellulitis.
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Aetiology
Orbital cellulitis is commonly caused by a local spreading infection from acute bacterial sinusitis, typically from the
paranasal sinuses.
Less common causes of orbital cellulitis include the extension of peri-orbital cellulitis, haematogenous spread, orbit
trauma (e.g. dog bite), or contiguous spread from the face or teeth from recent surgery or dental infection.
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Clinical features
History
Typical symptoms of orbital cellulitis include\:
Erythema and swelling around the eye
Blurred vision
Painful eye movements
Change in colour vision
Fever
Other important areas to cover in the history include\:
Past medical history\: previous episodes of eye disease including any previous episodes of peri-orbital/orbital cellulitis
History of precipitating cause\: for example orbital trauma, sinusitis, or dental infection
Duration of symptoms
Laterality (unilateral or bilateral)
Severity of symptoms (worsening, stable or improvement in symptoms since start)
Clinical examination
In the context of suspected orbital cellulitis, the following clinical examinations should be performed\:
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Nasal examination\: looking for ipsilateral nasal discharge/mucus
Oral cavity examination\: assessing oral hygiene, any evidence of dental disease, and any recent dental treatment of the
upper molars
Examination of the eyes and vision\: including assessment of visual colour vision, relevant a
pupillary defect (RAPD), light reslit lamp examination.
Neurological examination\: cranial nerve examination including assessment for meningism
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Typical clinical
Severe eye redness and swelling
Fever
Painful eye movements*
Reduced visual acuity and/or visual
Proptosis *
Relevant a
Chemosis *
Altered colour vision *(red-green tends to be the
Bilateral eye signs may indicate cavernous sinus thrombosis. Nausea, vomiting, headache, neck sti
intracranial involvement.
* The clinical
septal disease. These ‘grave eye signs’ are positive predictors of advanced disease, which includes abscess formation and
cavernous sinus thrombosis.
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These patients will need cross-sectional imaging and multidisciplinary involvement.
Figure 2. Orbital cellulitis.
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Investigations
Laboratory investigations
Relevant laboratory investigations include\:
Full blood count\: may show elevated white cell count, particularly neutrophilia
C-reactive protein (CRP)\: may be elevated
Lactate\: may be raised if the patient is septic
Blood cultures\: the most common isolated organisms include S t a p h y l o c o c c u s , S t r e p t o m y c e s species and H a e m o p h i l u s
Microscopy, culture and sensitivity swabs\: including swabs of the conjunctiva and nasopharynx
Imaging
Contrast-enhanced CT orbit, sinuses and brain is the imaging modality of choice.
Imaging is required to assess for complications of orbital cellulitis (including abscess formation or intracranial involvement)
and to guide ongoing management.
Imaging is indicated if clinical examination of the eye is not possible, there are any red
improve (e.g. ongoing pyrexia) after 36-48 hours of intravenous antibiotics.
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MR venogram may be required to aid the diagnosis of cavernous sinus thrombosis. If meningeal signs develop, lumbar
puncture is indicated. A CT head should be considered to exclude raised intracranial pressure prior to lumbar puncture.
Management
Patients with suspected orbital cellulitis require emergency referral to ophthalmology and ENT.
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Medical management
Patients with orbital cellulitis require intravenous antibiotics, for seven to ten days. Antibiotic choice depends on local
guidelines and results from microbiological investigations.
The patient will require multidisciplinary care (ophthalmology, ENT and paediatrics) and re-imaging if necessary.
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Surgical management
If an orbital collection is seen on imaging, evacuation of orbital pus or drainage of paranasal sinus pus may be required.
Chandlers classi
Chandler’s classi
cause of orbital cellulitis).
Although this is not a continuum of disease it is useful in diagnosis (especially as the di
It also provides a useful aid in guiding management of peri-orbital and orbital cellulitis.
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Group 1\: Pre-septal cellulitis (infection anterior to orbital septum)
Group 2\: Orbital cellulitis (infection posterior to orbital septum)
Group 3\: Subperiosteal abscess (pus collection between bone and periosteum)
Group 4\: Intraorbital abscess (pus collection within the orbit)
Group 5\: Cavernous sinus thrombosis (mural thrombus which may propagate centrally)
Broadly speaking, grade 1 can be treated medically with antibiotics. Grade 2 can also be treated medically however if
there is no improvement surgical drainage should be considered. Grade 3 and 4 can be treated surgically (drainage
endoscopically or externally). Grade 5 should be treated with anticoagulation as well as surgical drainage.
Complications
Complications of orbital cellulitis include\:
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Cavernous sinus thrombosis
Loss of vision
Intracerebral abscess
Meningitis
Death (rarely)
Key points
Orbital cellulitis is a sight-threatening infection in the muscle and fat within the orbit, posterior to the orbital septum.
Orbital cellulitis is commonly caused by contiguous spread of paranasal sinusitis.
Clinical features include a painful red eye with proptosis, chemosis, painful eye movements, and decreased acuity.
Initial investigations include an endonasal swab and FBC, CRP, and lactate. Imaging may include CT orbit, sinuses and
brain.
Medical management includes treatment with intravenous antibiotics, with surgery reserved for more complicated
orbital cellulitis.
If not recognised and treated promptly there is a risk of visual loss, intracranial spread and rarely death.
Peri-orbital cellulitis
Peri-orbital cellulitis (also called pre-septal cellulitis) is an infection in the eyelid tissues anterior to the orbital septum.
Peri-orbital cellulitis is a much more common and less serious than orbital cellulitis.
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Aetiology
Peri-orbital cellulitis is usually caused by super
upper respiratory tract infections or sinusitis.
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Clinical features
History
Typical symptoms of peri-orbital cellulitis include\:
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Pain, redness and swelling of the eyelid
Other important areas to cover in the history include\:
Recent insect bites, styes/chalazions, recent upper respiratory tract infections
Clinical features
A thorough clinical examination is required to exclude orbital cellulitis and red
for the examinations that should be performed.
Typical clinical features of peri-orbital cellulitis include\:
Eyelid redness, mild tenderness and swelling
Fever
Unlike orbital cellulitis, patients with peri-orbital cellulitis are unlikely to experience signi
Visual acuity and visual
and there will be no sign of chemosis or proptosis. A fever may or may not be present in peri-orbital cellulitis.
Patients with peri-orbital cellulitis are systemically well and symptoms are less severe. If there is severe eyelid swelling it
may be di
Table 1. Di
Peri-orbital
cellulitis
Proptosis No Yes
Orbital cellulitis
Eye
movements
Painful and
Normal
restricted
Visual acuity Normal May be reduced
Colour vision Normal May be reduced
RAPD No Yes, in severe cases
Figure 3. Peri-orbital cellulitis.
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Investigations
There are no speci
If there is any suspicion of orbital cellulitis or the diagnosis is unclear, referral to secondary care for further investigation is
required (see orbital cellulitis section).
Management
Consider emergency referral to ophthalmology/ENT if there is any suspicion of orbital cellulitis, the patient is systemically
unwell, or not responding to treatment.
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Paediatric patients should be urgently referred as they require empirical intravenous antibiotic treatment and daily review
due to the di
history and can be challenging to examine.
For adult patients, oral co-amoxiclav is usually prescribed
review in 24-48 hours and safety netting advice should be provided to the patient.
As for orbital cellulitis, if a sinogenic cause is suspected then patients require intranasal treatment.
Complications
Peri-orbital cellulitis can spread to cause orbital cellulitis and its subsequent sequelae. As a result, it is important to
provide adequate safety netting advice to patients with peri-orbital cellulitis.
Final summary
Peri-orbital and orbital cellulitis are dependent on whether the infection is anterior or posterior to the orbital septum.
Patients with either of these conditions may present with a red swollen, tender eye and a fever. Di
orbital cellulitis (sight-threatening) and peri-orbital cellulitis (less severe) is challenging. If there is diagnostic uncertainty,
early referral to ophthalmology/ENT for assessment and consideration of imaging is required.
References
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Reviewer
Mr Rakesh Mistry
ENT Registrar
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