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Periorbital Cellulitis

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Overview

Also known as preseptal cellulitis, periorbital cellulitis is the infection of the tissues around the eye anterior to the orbital septum with ocular function remaining intact. It is common in children and can progress to orbital cellulitis. Periorbital cellulitis is more common and less severe than orbital cellulitis.

The infection usually spreads from surrounding structures, typically from an upper respiratory tract infection such as sinusitis.

Causes

  • The most common pathogens are:
    • Staphylococcus aureus
    • Streptococcus pneumoniae
    • Streptococcus pyogenes
    • Haemophilus influenzae – more common in children

Other rarer causes are:

  • Fungal infections e.g. mucormycosis/aspergillosis – more common in immunosuppression or diabetic ketoacidosis 

Epidemiology

  • Both orbital cellulitis and periorbital cellulitis are more prevalent in the winter months due to an increased prevalence of upper respiratory tract infections
  • Both orbital cellulitis and periorbital cellulitis are more common in children

Risk Factors

  • Sinusitis
  • Young age
  • Lack of Haemophilus influenzae type B vaccination

Presentation

Pero-orbital cellulitis usually presents with redness around the eyelid without significant pain. Some features are:

  • Erythema and eyelid swelling
  • Ptosis of the eye due to swelling
  • There may be a fever

It can be difficult to distinguish preorbital cellulitis from orbital cellulitis, so it is essential to have a low threshold of suspicion. Any of the following features should raise suspicion for orbital cellulitis:

Differential Diagnoses

Orbital cellulitis

  • May be difficult to distinguish
  • Consider orbital cellulitis if any of the following are present:
    • Pain with eye movement
    • Restrictions in eye movements
    • Visual disturbances
    • Chemosis
    • Presence of a relative afferent pupillary defect
    • Leukocytosis
    • Fevers in children

Thyroid eye disease

Investigations

  • Immediate referral to secondary care for assessment
  • FBC and white cell count:
    • May show leukocytosis
  • CT of the orbits with contrast:
    • Differentiates between orbital cellulitis and periorbital cellulitis

Management

All patients

  • Immediate referral to secondary care
    • Children are generally admitted for observation
  • If suitable for outpatient management:
    • 1st-line: empirical oral antibiotics
      • Options are: amoxicillin or cefuroxime + metronidazole
  • If hospitalisation is required:
    • 1st-line: empirical IV antibiotics
      • Options are: cefotaxime or clindamycin or cefuroxime + metronidazole
  • Once cultures and sensitivities are known, switch to targeted antibiotic therapy
  • Surgery is indicated if:
    • There is CT evidence of orbital collection
    • There is no response to antibiotics
    • Visual acuity decreases
    • There is an atypical presentation and a biopsy is considered

Complications

  • Progression into orbital cellulitis
  • Meningitis
  • Orbital abscesses
  • Ocular compartment syndrome and subsequent vision loss

Prognosis

  • Early diagnosis and intervention usually lead to a complete and uncomplicated recovery.

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