Basics
Description
- Periorbital or preseptal cellulitis is an acute infection characterized by pain, erythema, and edema to the anterior eyelid and surrounding tissue.
- The infection lies superficial to orbital septum, a thin fascial layer forming the anterior boundary of the orbital compartment.
- In contrast, orbital cellulitis is an infection involving the deeper structures of the orbit and requires emergent intervention.
Epidemiology
- Often occurs in young children, commonly <5 years of age, but can occur at any age
- Periorbital cellulitis is at least three times more common than orbital cellulitis.
Risk Factors
Predisposing factors that may lead to infection include skin trauma and lacrimal/eyelid injury.
Pathophysiology
- Often, extension from an external source including trauma (insect bite, recent surgery, foreign body) or adjacent infection (sinusitis, dacryocystitis, hordeola, dental abscess)
Etiology
- Variable depending on mechanism
- Most common pathogens are Staphylococcus aureus (increasingly methicillin-resistant) and Streptococci species.
- Anaerobic infections can extend from dental source.
- Haemophilus influenza type B was historically the most common pathogen; consider in unimmunized child younger than 5 years of age.
Commonly Associated Conditions
- Rarely associated with bacteremia; however, consider this condition in children younger than 3 years of age or in immunocompromised patients.
Diagnosis
History
- Onset, time course of symptom progression, and any predisposing factors
- A history of trauma is suggestive of periorbital cellulitis.
- The presence of pain supports cellulitis, whereas complaints of pruritus are more suggestive of an allergic etiology.
- Diplopia and visual changes are more suggestive of orbital cellulitis.
- Quantify systemic symptoms such as fever and lethargy.
- These indicate a more severe, disseminated infection.
Physical Exam
- Superficial orbital tissues and lids will be edematous, erythematous, warm to the touch, and typically tender on palpation.
- Often unilateral, the findings can start in one eyelid, but both the upper and lower eyelids are usually involved.
- May be signs of previous trauma, cutaneous injury, etc.
- Occasionally, the eyelids are so swollen that it is difficult to examine the globe. To do so, place anesthetic eyedrops on the eye and use ocular speculum or fashion a paperclip into a lid retractor to lift the eyelid.
- The globe should be carefully examined.
- In periorbital cellulitis, the ocular exam is often normal. The sclera is usually white, although patients can have some conjunctival erythema but rarely chemosis.
- Any change in vision, pupillary function, or limitations in eye motility suggests orbital involvement.
- The presence of proptosis and/or pain with eye movement suggests deep orbital involvement.
- Neurologic findings, such as cranial nerve deficit, are suggestive of deep space involvement.
- Evaluate for signs of fever, respiratory infection, and sepsis.
Diagnostic Tests & Interpretation
Lab
- Lab tests are usually not helpful or indicated.
- CBC is warranted only if bacteremia is suspected.
- Leukocytosis has no value in differentiating periorbital and orbital cellulitis.
- Skin cultures and blood cultures have a low yield.
- Blood cultures are obtained only when the child is febrile or appears septic.
- Wound cultures can be obtained if there is an abscess.
Imaging
- Periorbital cellulitis is a clinical diagnosis and radiologic confirmation is only indicated if the diagnosis is unclear. Imaging may be required in the following circumstances:
- If orbital cellulitis is suspected
- Cases that do not respond to medical treatment
- Neurologic symptoms are present.
- Serial CT scanning should be done only if the child is not improving with treatment.
Differential Diagnosis
- Infectious
- Early orbital cellulitis, dacryocystitis, stye, severe viral conjunctivitis
- Orbital cellulitis is an ophthalmologic emergency and requires prompt therapy.
- Allergic
- Periocular allergic reaction: insect bite, angioedema, contact dermatitis
- Other
- Periocular trauma
- Rhabdomyosarcoma
- Idiopathic orbital inflammatory syndrome (IOIS)
- Cavernous venous thrombosis
- Hypoproteinemia
Treatment
General Measures
- Simple periorbital cellulitis should be empirically treated based on local prevalence of Staphylococcus and Streptococcus species.
- Consider MRSA
- Examples include second-generation cephalosporins or ²-lactamase " resistant penicillins.
- There is no evidence to suggest that intravenous are better than oral antibiotics; however, younger children need close observation and/or follow-up.
- For children <1 year of age, strongly consider hospitalization for IV therapy and very close observation.
- Children between the ages of 1 and 5 years should either be hospitalized or arranged for close follow-up after initiating antibiotics.
- Children >5 years of age can usually be treated with an oral regimen as long as they do not appear toxic or have orbital involvement.
- Any patient with symptoms suggestive of deep space involvement or hematogenous involvement should be hospitalized.
Medication
- In nontoxic children, oral antibiotics: amoxicillin/clavulanate, cefalexin, clindamycin (if MRSA is a concern), etc. are started on an outpatient basis; the child should be seen again within 24 " 48 hours.
- Consider admission for IV antibiotics (clindamycin, ampicillin/sulbactam, etc.) for those patients younger than 1 year of age, ill appearing, have bacteremia, or symptoms suggestive of orbital involvement.
Surgery/Other Procedures
Surgical intervention is usually required when an abscess or a foreign body is present.
Ongoing Care
- Patients should have close follow-up 24 " 48 hours after initiating outpatient treatment.
- Patients who do not improve after close follow-up should be admitted for IV antibiotics and imaging.
- Patients should be seen daily until a definite improvement is noted.
Prognosis
Excellent, with minimal incidence of long-term sequelae, unless a complication is encountered
Complications
- Orbital extension (2.5 " 17%)
- Skin abscess (8%)
- Eyelid necrosis (1 " 2%)
- Sepsis
- Intracranial extension (2 " 3%)
Patient Monitoring
- Watch patients closely for signs of orbital extension, bacteremia, or other forms of disseminated infection.
- Neonates and infants can become septic very quickly, so they need to be closely monitored.
Additional Reading
- Bedwell J, Bauman N. Management of pediatric orbital cellulitis and abscess. Curr Opin Otolaryngol Head Neck Surg. 2011;19(6);467 " 473. [View Abstract]
- Donahue SP, Schwartz G. Preseptal and orbital cellulitis in childhood: a changing microbiologic spectrum. Ophthalmology. 1998;105(10):1902 " 1905. [View Abstract]
- Foster JA, Katowitz JA. Pediatric orbital and periocular infections. In: Katowitz JA, ed. Pediatric Oculoplastic Surgery. New York, NY: Springer-Verlag; 2001:407 " 420.
- Georgakopoulos CD, Eliopoulou MI, Stasinos S, et al. Periorbital and orbital cellulitis: a 10-year review of hospitalized children. Eur J Ophthalmol. 2010;20(6):1066 " 1072. [View Abstract]
- Hauser A, Fogarasi S. Periorbital and orbital cellulitis. Pediatr Rev. 2010;31(6);242 " 249. [View Abstract]
- Lessner A, Stern GA. Preseptal and orbital cellulitis. Infect Dis Clin North Am. 1992;6(4):933 " 952. [View Abstract]
- Powell KR. Orbital and periorbital cellulitis. Pediatr Rev. 1995;16(5):163 " 167. [View Abstract]
- Rutar T, Chambers HF, Crawford JB, et al. Ophthalmic manifestations of infections caused by the USA300 clone of community-associated methicillin-resistant Staphylococcus aureus. Ophthalmology. 2006;113(8):1455 " 1462. [View Abstract]
- Wald ER. Periorbital and orbital infections. Pediatr Rev. 2004;25(9):312 " 320. [View Abstract]
- Vayalumkal JV, Jadavji T. Children hospitalized with skin and soft tissue infections: a guide to antibacterial selection and treatment. Paediatr Drugs. 2006;8(2):99 " 111. [View Abstract]
Codes
ICD09
- 376.01 Orbital cellulitis
- 373.13 Abscess of eyelid
ICD10
- H05.019 Cellulitis of unspecified orbit
- H00.039 Abscess of eyelid unspecified eye, unspecified eyelid
- H05.012 Cellulitis of left orbit
- H05.011 Cellulitis of right orbit
SNOMED
- 109245003 Cellulitis of periorbital region
- 109242000 Abscess of periorbital region (disorder)