• Shruti GOCHHWAL

Periorbital Cellulitis: Causes, Symptoms, Diagnosis, and Treatment

Periorbital cellulitis is an eyelid and/or skin infection. Though adults can get periorbital cellulitis, children under the age of two are more likely to get this condition.

This normally occurs whenever the soft tissue is attacked by bacteria including your eyelid. The germs enter the skin through a cut or scratch, or an infection in the sinuses. Periorbital cellulitis is also caused by trauma.

Periorbital cellulitis, which occurs outside a skull called orbital septum, is often referred to as preseptal cellulitis. Although the tissue layer prevents the virus from spreading to the eye, it does not typically impact the vision. Some findings show that mortality ranges from 5% to 25% in intracranial periorbital or orbital cellulitis.

How Does Periorbital Cellulitis Differ From Orbital Cellulitis?

Periorbital cellulitis

A child, Credits: pixabay


Orbital cellulitis and periorbital cellulitis are a distinct diseases that shares a few clinical signs and symptoms. Orbital cellulitis normally starts deeply within the orbital septum, and periorbital septum cellulitis begins superficially. Orbital cellulitis has additional clinical characteristics such as proptosis, eye pain, lower vision and reduced motility. Both disorders between children are normal. Periorbital cellulitis is much more widespread than orbit cellulitis.

Cellulitis of the orbit is a major complication, which can lead to partial loss of vision, complete blindness, and other life threats. In the case of periorbital cellulitis, the infection can spread to the eye socket and cause orbital cellulitis.

Orbital Complications Classification

As periorbital and orbital cellulitis share certain similarities, it is important to distinguish them to devise proper treatment plans. The Chandler orbital complication division assigns orbital complications according to their severity. In making a diagnosis it is important to understand these types. The groups are:

  1. Group 1 pre-septal cellulitis

  2. Group 2 orbital cellulitis

  3. Group 3 subperiosteal abscess

  4. Group 4 orbital abscess

  5. Group 5 cavernous sinus thrombosis.

What Are The Causes Of Periorbital Cellulitis?

Periorbital cellulitis Causes

Bacteria, Credits: pixabay


Preseptal cellulitis is typically due to the concurrent spread of local facial or eyelid damage, insect or animal bites, conjunctivitis, chalazion, or sinusitis infections.

Periorbital cellulitis is caused by bacteria, viruses, fungi, and helminths. Bacteria are the cause of the majority of infections.

The pathogen type may differ. Streptococcus pneumonia and Staphylococcus aureus and S. pyogenes are generally the most common pathogen associated with a sinus infection where the infection is caused by local Trauma.

The less common causes of periorbital cellulitis include

Acinetobacter, Nocardia, Bacillus, Pseudomonas, Neisseria, Proteus, Pasteurella, and Mycobacterium. Fungal infections can be Mucorales and Aspergillus. However, fungal infections are very rare.

In children who are less than 9 years old, the infection is usually caused by a single aerobic organism and in children who are more than 15 years old, the infection is supposed to be polymicrobial with mixed aerobic and anaerobic (Bacteroides, Peptostreptococcus) infections.

The common risk factors for periorbital and orbital cellulitis are presented in the table below.

Risk FactorsPercentageConjunctivitis 74.1%Upper respiratory tract infections 37.4%Focal lesions on the face or near the orbita 25.2%Sinusitis 24.5%Odontogenic infections and dental caries 19.4%Trauma 10.8%Allergy 3.6%Hordeolum 3.6%Other 6.5%

What Are The Symptoms Of Periorbital Cellulitis?

Symptoms

Infection, Credits: pixabay


The most common signs of periorbital cellulitis are:

  1. Redness in the eyes and swelling

  2. Tenderness, heat and eyelid discoloration

  3. Cut, scratch, or bite close to the eye

  4. The white side of the eye could look red.

  5. Eye pain

  6. Low-grade fever

Patients find difficulties in opening the eye because of swelling in the eyelids. And if an eye evaluation is difficult, visual acuity does not usually affect the eye function, and the globe does not push forward.

Periorbital cellulitis usually does not cause fever or pain. If your child develops fever and swelling and the affected eye finds difficulty in movement, it is important to get medical attention.  As these symptoms are more related to a serious medical issue called orbital cellulitis which affects the eye, it is important to find medical help immediately.

Diagnosis of Orbital Cellulitis

Physical Examination

An ophthalmologist performs an eye examination. Preseptal and orbital cellulitis have distinct clinical characteristics and can be clinically distinguished. In periorbital cellulitis except for eyelid swelling, other eye findings remain normal.

If a doctor suspects that your child may have periorbital cellulitis, he will observe for signs of injury or a stye. Also, he will examine how well your child can move her eyes and respond to light. They may order more testing after clearly identifying the symptoms of an infection such as redness, swelling and pain.

Blood Test

Periorbital cellulitis Diagnosis

Blood test, Credits: pixabay


A blood test or any drainage from the eye will be collected. This is to determine which bacteria cause the problem.

Blood Cultures

Blood cultures are carried out in patients with orbital cellulitis before antibiotics are started. However, less than one third are positive. If meningitis is suspected, a lumbar puncture is done. When the supposed cause is sinusitis, paranasal fluid cultures are performed.

CT Scan

Periorbital cellulitis Diagnosis

A doctor interpreting a CT scan, Credits: canva


If nasal discharge is present and to rule out orbital cellulitis, tumors and pseudotumor, a CT or MRI analysis can be carried out. A scan of orbits and sinuses by computed tomography(CT) allows differentiation and determination of infection levels in orbital and periorbital cellulitis. If marked eyelid swelling, fever, leukocytosis, or no improvements with the proper antibiotic then a CT scan should be carried out.

The degree of orbital activity can be determined by a computed tomography scan. The following results for the CT scan in preseptal cellulitis include:

  1. Swelling of the eyelid and surrounding soft tissues

  2. Obliteration of the fat planes or soft tissue details

  3. Absence of orbital inflammation

IPeriorbital (preseptal) and orbital cellulitis are difficult to differentiate based solely on clinical results, especially among children.

Many clinical symptoms of orbital cellulitis are different, such as proptosis and ophthalmoplegia, but a CT scan with a contrast infusion in the orbit confirms the proper diagnosis.

Orbital ultrasound can assist with orbital inflammation diagnosis which needs skilled observers and expert facilities.

MRI

The benefit of magnetic resonance imaging (MRI) over the CT scan is that it best measures the pathology of soft tissues. MRI helps diagnose cavernous sinus thrombosis. Imaging with diffusion will confirm most orbital abscesses in patients who do not undergo the intravenous contrast dye without the use of intravenous contrast dye (e.g., those who have renal insufficiency).

Despite the advantages, MRI is not commonly used as it becomes not readily available in certain clinical settings, and pediatric patients there is a need for sedation before obtaining an MRI.

Treatment of Orbital Cellulitis

treatment

A woman taking antibiotics, Credits: canva


Preseptal cellulitis, when extended to the eyes’ socket, can cause vision problems and blindness. The right treatment is necessary to prevent complications.

A doctor can prescribe antibiotics if they confirm that your child is suffering from periorbital cellulitis. Either orally or intravenously, these antibiotics can be taken. The type of the prescribed antibiotic may vary depending on the type of bacteria causing an infection and your age. It should begin working within 24 to 48 hours.

The first treatment is against pathogens in sinusitis (S. pneumoniae, non-typeable H. influenzae, S. aureus, Moraxella catarrhalis). Clinicians will apply effective antibiotics in regions where methicillin-resistant S. aureus is present. Gram-negative infection must be taken into account in patients with dirty wounds.

If periorbital cellulitis happens in adults, oral antibiotics are prescribed. If they do not respond to oral antibiotics, intravenous antibiotics are prescribed. Adults usually receive the following antibiotics.

  1. Amoxicillin/clavulanate

  2. Clindamycin

  3. Doxycycline

  4. Trimethoprim

  5. Piperacillin/tazobactam

  6. Cefuroxime

  7. Ceftriaxone

If periorbital cellulitis is seen in children who are less than one year old, intravenous antibiotics are given in the hospital. Children will be discharged if the doctor feels that the intravenous antibiotics are working. They will be given oral antibiotic medications to be continued at home for a few more days. The commonly prescribed antibiotics in children include the following.

  1. Amoxicillin/clavulanate

  2. Clindamycin

  3. Doxycycline

  4. Trimethoprim

  5. Piperacillin/tazobactam

  6. Cefuroxime

  7. Ceftriaxone

The treatment regimens for different cellulitis are described in the table below.Orbital

cellulitis

Severe Periorbital cellulitis3rd generation cephalosporin

Cefotaxime 50 mg/kg (max 2 g) IV 6 hourly OR

Ceftriaxone 50 mg/kg (max 2 g) IV daily

PLUS

Flucloxacillin 50 mg/kg (max 2g) IV 6 hourly OR

If suspected MRSA: vancomycin 

Duration based on clinical severity and improvement. Usually at least 3-4 days, then switch to oral.Amoxicillin with clavulanic acid (doses based on amoxicillin component) 22.5 mg/kg (max 875 mg) oral bd

10–14 daysModerate Periorbital cellulitisFlucloxacillin 50 mg/kg (max 2g) IV 6 hourly 

OR

Ceftriaxone 50 mg/kg (max 2g) IV daily (consider HITH)

OR

If suspected MRSA:

Clindamycin 15 mg/kg (max 600 mg) IV/oral 8 hourly OR

Trimethoprim with sulfamethoxazole (8/40 mg/mL) 4/20 mg/kg (max 320/1600 mg) bd 

Duration based on clinical severity and improvement. Usually 1-2 days, then switch to oral.When improving, switch to oral antibiotics as per mild periorbital cellulitis7–10 daysMild Periorbital cellulitisNot applicableCefalexin 33 mg/kg (max 1 g) oral tds                           ORCefuroxime 3 months – 2 years: 10 mg/kg (max 125 g) oral bd                           2 – 12 years: 15 mg/kg (max 250 mg) oral bd7-10 days

A follow-up visit is necessary to find whether the infection is completely gone.

How Long Does It Take For Periorbital Cellulitis To Go Away?

Treatment is often prescribed for seven to ten days, but treatment should proceed until symptoms of cellulitis are resolved or almost resolved until eyelid erythema and swelling have occurred.

Recurrent preseptal cellulitis rarely recurs.  It normally comes in because of an underlying cause not diagnosed or an anatomical abnormality.

In addition to antibiotic treatment, surgical drainage is indicated by the presence of subperiosteal and intraorbital abscess. For full ophthalmology and/or severe optic impairment (acute optic nerve or retinal compromise) or major and specified abscesses, surgical drainage is suggested.

In patients with orbital cellulitis, intracranial abscess drainage, orbital surgery, or ethmoidectomy, sinus surgery and Sinus endoscopy are advised, depending on the patient conditions.

What Are The Complications Of Periorbital Cellulitis?

Complications

Meningitis, Credits: canva


The complications of periorbital cellulitis include the following.

  1. Recurrent periorbital cellulitis (RPOC) – Three periorbital infections within 1 year spread up to a period of 1 month of convalescence

  2. Toxic shock syndrome

  3. Eschar formation leading to scarring

  4. Meningitis

  5. Orbital cellulitis

  6. Intracranial extension of infection

  7. Periorbital necrotizing fasciitis – A potential complication with devastating results; the mortality rate is reported to be 14.4% [44]

Is Periorbital Cellulitis An Emergency?

If your child has swelling, redness in the eyelids and fever seek medical attention. Sometimes periorbital cellulitis can turn to orbital cellulitis and cause vision problems and blindness.

6 views0 comments