Definition
• Infxn’s of eyelids, orbit, & surrounding structures. Separated by orbital septum
• Periorbital cellulitis is a simple skin infxn and involves structures anterior to septum. Orbital cellulitis is posterior to septum; involves infxn of soft tissues w/i the orbit
Pathophysiology (Pediatr Infect Dis J 2002;12:1157)
• Periorbital infxn 2/2 direct inoculation of bacteria (trauma, insect bite) or via bacteremia
• Etiology if 2/2 trauma usually skin flora (S. aureus, GAS); if bacteremia, S. pneumo
• Orbital infxn generally sinusitis complication w/ infxn extension, rarely 2/2 trauma
• Periorbital cellulitis does not spread and become orbital cellulitis (Pediatr Infect Dis J 2002;12:1157)
• Ethmoid sinus most common source; separated from orbit by thin lamina papyracea
• Bacteria same as sinusitis (S. pneumo, nontyp H. influ, M. catar, GAS, S. aureus, anaerobes)
Clinical Manifestations (Pediatr Infect Dis J 2002;12:1157)
• Essential to differentiate the 2 entities; can be challenging as symptoms overlap
• Periorbital cellulitis p/w erythema, induration, tenderness, and warmth of eyelid and periorbital tissue. No limitations or pain w/ eye mvmt. Systemic sx infrequently present
• Orbital cellulitis w/ same superficial inflamm, but w/ vision Δs, pain w/ and limitation
of eye mvmt, chemosis (edema of bulbar conjunctiva), or proptosis (Pediatr Rev 2004; 25:312)
• Eye pain can precede signif swelling; impaired ocular mvmt usually w/ upward gaze
Differential (Pediatr Rev 2004;25:312)
• Noninfectious causes of periorbital swelling
• Blunt trauma (black eye), p/w ecchymosis/swelling; ↑ first 48 hr then slowly resolves
• Tumor usually more gradual onset, w/ proptosis but usually no inflammation
• Hemangioma of the lid; stereotypical vascular appearance
• Ocular tumors (retinoblastoma, choroidal melanomas)
• Orbital neoplasms (neuroblastoma, rhabdomyosarcoma)
• Allergy w/ either hypersensitivity (more itchy than painful) or angioedema
• Local edema 2/2 over hydration, CHF, or hypoproteinemia, usually w/o tenderness
• Infections that can be mistaken for preseptal cellulitis
• Dacryoadenitis: Infxn of lacrimal gland w/ sudden and max at onset inflamm at outer upper eyelid (viral [EBV, mumps, CMV, Coxsackie, echo, VZV] or bacterial)
• Dacryocystitis: Bacterial infxn of lacrimal sac as complication of URI w/ inflamm most prominent at medial corner of the eye
• Hordeolum: Infxn of sebaceous glands at eyelashes base; meibomian gland abscess
Diagnostic Studies
• No imaging needed with periorbital cellulitis
• CT of orbits/sinuses for orbital cellulitis, esp if persistence or worsening sx on appt Rx
Treatment (Pediatr Rev 2004;25:312)
• For periorbital cellulitis, Rx PO if >1 yo and full vac w/o systemic sx to cover Gram+’s
(cephalexin, dicloxacillin, clinda). Good outpt f/u. Duration of Rx: 7–10 d
• For orbital cellulitis, Rx w/ IV Abx against potential pathogens
• Amp/sulbactam ≥200 mg/kg/d divided q6h. Add vancomycin if MRSA suspected. Duration of Rx depends on clinical picture; usually 3 wk (w/ 1st 5–7 d parenterally)
• Pts w/ large, well-defined abscess, ophthalmoplegia and/or visual impairment, or those w/o clinical improvement w/ 24–48 hr of IV Abx usually require surgical drainage of abscess and involved sinuses (J Fam Pract 2007;56:662)