Periorbital Cellulitis

Periorbital (preseptal) cellulitis is infection of the eyelid and periocular tissue anterior to the orbital septum. It must be separated from orbital cellulitis, which lies behind the septum and threatens vision and life.

• Sources: skin trauma, insect bites, stye, dacryocystitis, sinusitis, dental infection, eyelid surgery.
• Organisms: Staphylococcus aureus, Streptococcus pneumoniae and pyogenes; Haemophilus influenzae type b in unimmunised children.
• Most common in children under 5 years.

Red, swollen, tender, warm eyelid, often with fever; normal eye movements, normal vision and no proptosis.

• Orbital signs (suggesting orbital cellulitis): pain on eye movement, restricted movement, diplopia, proptosis, reduced visual acuity, colour vision loss, afferent pupillary defect, chemosis.
• Differential diagnosis: orbital cellulitis, allergic or contact dermatitis, angioedema, insect bite, herpes zoster ophthalmicus, chalazion, dacryocystitis, conjunctivitis, thyroid eye disease, trauma, rhabdomyosarcoma, retinoblastoma.
• Complications: orbital cellulitis, subperiosteal abscess, cavernous sinus thrombosis, meningitis, brain abscess, optic neuropathy and blindness, eyelid abscess.

Clinical, with a thorough eye examination.

• Visual acuity, pupils, eye movements, proptosis, colour vision; full blood count, CRP, blood cultures if febrile.
• CT orbits and sinuses with contrast when any orbital sign, severe illness, no improvement at 24 to 48 hours of antibiotics, or inability to examine a child.
• Examine for sinusitis, dental and skin sources; HIV test where indicated.

Antibiotics against Staphylococcus and Streptococcus; admit if orbital signs.

• Supportive: warm compress, analgesia (paracetamol 15 mg/kg or 1 g), saline nasal rinses and decongestant for sinusitis, review daily.
• Pharmacological: mild preseptal cellulitis in a well child over 1 year or adult: amoxicillin clavulanate 625 mg three times daily (children 30 mg/kg/day of the amoxicillin component in three doses) for 7 to 10 days; cefalexin 500 mg four times daily (children 25 mg/kg four times daily) with metronidazole if sinus or dental source; penicillin allergy: clindamycin 300 mg three times daily (children 7 mg/kg three times daily). Severe or orbital: ceftriaxone 2 g IV daily (children 100 mg/kg/day) with metronidazole 500 mg IV every 8 hours, plus vancomycin 15 to 20 mg/kg IV every 12 hours where MRSA is likely; continue 14 to 21 days. Topical oxymetazoline 0.05 percent nasal spray twice daily for 3 days.
• Procedures: drainage of subperiosteal or orbital abscess; endoscopic sinus surgery; dental extraction.
• Special groups: pregnancy, amoxicillin clavulanate; infants under 1 year, admit for IV therapy; immunocompromised and diabetic, admit.
• Red flags: proptosis, painful or restricted eye movement, diplopia, visual loss, afferent pupillary defect, severe headache, drowsiness, fever beyond 48 hours of treatment.
• Follow-up: review within 24 hours of starting oral therapy; urgent ophthalmology and ENT review when orbital signs appear.