orbital_cellulitis
Table of Contents
Periorbital and orbital cellulitis
see also:
Introduction
- periorbital (“preseptal”) cellulitis is superficial and does not extend deep to the orbital septum but may do so in which case it becomes orbital cellulitis
- orbital cellulitis extends deep to the orbital septum and risks permanent eye damage, intracranial infection and sepsis
- infection is generally either local spread from soft tissues or sinuses, but may be systemically spread with seeding from bacteraemia / septicaemia eg. H. influenzae type b (HiB)
- HiB vaccination of children since the early 1990s has practically eradicated life-threatening childhood invasive HiB infection such as orbital cellulitis, meningitis, septicaemia and epiglottitis
- usual pathogens are Staph. aureus, Strept, H. influenzae type b (HiB), anaerobes, and in immunocompromised or diabetics, fungi may be the cause
- orbital cellulitis is a rare emergency with risk of septic shock, intracranial spread (brain abscess or meningitis) and ocular damage and thus needs to be explicitly differentiated from periorbital cellulitis
- features suggestive of orbital cellulitis rather than just periorbital cellulitis include:
- children aged under 4yrs are at particular risk, especially if not vaccinated for H. influenzae type b (HiB)
- immunocompromised patients
- systemically unwell
- fever
- chemosis
- proptosis
- diplopia
- painful eye movements
- impaired visual acuity or visual fields
- presence of a more likely aetiology such as:
- orbital trauma
- post-op
- foreign body in orbit
- NB. examination of the eye may be very difficult due to extreme swelling but should be pursued or CT scan performed if examination cannot exclude orbital cellulitis
- NB. both periorbital and orbital cellulitis may be due to odontogenic sinusitis, dacrocystitis, or local infection but patients with periorbital cellulitis alone tend to be afebrile without eye signs or fever
- necrotising fasciitis of the face is extremely rare
- here is a case: necrotising fasciitis from an otherwise innocuous minor cut 1)
Mx of periorbital cellulitis in adults
- those who are at low risk for HiB infection without concurrent sinusitis are generally covered for Staph. aureus
- those with sinusitis or at risk of HiB are generally Rx with broad spectrum antibiotics - see your local guidelines
- patients should be reviewed in 24hrs for response to Rx and exclusion of signs of orbital cellulitis
Mx of orbital cellulitis
- blood cultures
- usual bloods
- if septic, start IV antibiotics ASAP (preferably within 1 hr)
- eg. ceftriaxone + flucloxacillin (use vancomycin instead if MRSA risk) - see your local guidelines
- resuscitate as usual if septic shock
- urgent CT scan orbits and sinuses +/- CT brain if brain abscess is suspected
- 4hrly eye obs - acuity and pupillary reaction
- may require urgent surgical drainage to avoid permanent visual loss
DDx
- need to distinguish cellulitis from:
- allergic reaction - usually bilateral and non-tender to light touch
- gravitational oedema / bruise from a forehead injury
- dermatological rashes
orbital_cellulitis.txt · Last modified: 2025/10/08 07:52 by gary1