1. Periorbital and Orbital Cellulitis
Adaobi Okobi, M.D.
Pediatrics Chief Resident
St. Barnabas Hospital

2. Objectives
Differentiate between periorbital and orbital cellulitis based on history and physical exam
Discuss the causes and treatments of periorbital and orbital cellulitis
Review the indications for imaging and ophthalmology consultation for eyelid swelling
Recognize the complications of periorbital and orbital cellulitis

3. Simplified anatomy of the eye, paranasal sinuses, and venous drainage
Orbital septum- thin membrane separating the superficial eyelid from the deeper orbital structures; anterior to the septum= periorbital and posterior to the septum=orbital
Hauser, A. et al. Pediatrics in Review 2010;31:
Copyright ©2010 American Academy of Pediatrics

4. Pathogenesis Sinusitis
Extension of external ocular infection (ie hordeolum, dacryocystitis/dacroadenitis)
Dental abscess
Superficial break in the skin (ie infected bug bite, acne, eczema, periocular surgery or direct penetrating trauma)
Hematogenous spread
More prevalent in children younger than 5 years; periorbital 3x more common than orbital
Sinuses surround the orbit on 3 sides and an infection could affect the orbit
Dacryocystitis/dacroadenitis- infection of the lacrimal system
Valveless orbital veins can allow for hematogenous infection in either antegrade or retrograde direction

5. Organisms Haemophilus influenza type b (before Hib vaccine in 1985)
Staphylococcus aureus (including MRSA)
S. epidermidis
Streptococcus pyogenes

6. History Past sinus disease? Past dental disease? Previous eye surgery?
History of trauma?

7. Physical Exam Observe for degree of ocular swelling
Assess extraocular movement
Evaluate for foreign body
Assess visual acuity

8. Clinical Signs and Symptoms
Unilateral erythema of eyelid
Swelling of eyelid
Warmth of eyelid
Tenderness of eyelid
Blurred vision
Ophthalmoplegia
Proptosis
Chemosis
Signs of increased intraocular pressure

9. Imaging: Indications
Eyelid edema that makes a complete examination impossible
Presence of CNS involvement (ie seizures, focal neurologic deficits, or altered mental status)
Deteriorated visual acuity or color vision
Proptosis
Ophthalmoplegia
Clinical worsening or no improvement after hours

10. Periorbital cellulitis

11. Hauser, A. et al. Pediatrics in Review 2010;31:242-249
A 15-month-old girl who has periorbital cellulitis and fever following infection of an insect bite to her lower right eyelid despite treatment with several days of cephalexin
Hauser, A. et al. Pediatrics in Review 2010;31:
Copyright ©2010 American Academy of Pediatrics

12. Hauser, A. et al. Pediatrics in Review 2010;31:242-249
An 11-year-old boy who has pan-sinusitis and left orbital cellulitis and presented with fever, severe left eye pain, proptosis, chemosis, and limitation of extraocular movements
Hauser, A. et al. Pediatrics in Review 2010;31:
Copyright ©2010 American Academy of Pediatrics

13. Differential Diagnosis
Allergic reaction
Edema from hypoproteinemia
Orbital wall infarction
Subperiosteal hematoma
Orbital pseudotumor
Orbital myositis
Retinoblastoma
Metastatic carcinoma
Exophthalmos secondary to thyroid dysfunction
Orbital pseduotumor- presents with pain, proptosis, local swelling, conjunctival injection; may have diplopia, visual loss, ptosis and limited extraocular movements; CT demonstrates inflammatory changes and an abnormal mass density of the intraorbital soft tissues; tx: corticosteroids

14. Admission Criteria Patients with orbital cellulitis presenting with:
Eyelid edema
Diplopia
Reduced visual acuity
Abnormal light reflexes
Ophthalmoplegia
Proptosis
Appears toxic
Eye exam is unable to be completely performed
Signs of CNS involvement:
Lethargy
Vomiting
Seizures
Headache
Cranial nerve deficit

15. Management
Depends on the patient’s appearance, ability to take oral medications, compliance and clinical progression of the disease
Empiric antibiotics should cover Staphylococcus and Streptococcus species, particularly MRSA
Treat for 7-10 days for periorbital cellulitis
Treat for days for orbital cellulitis
If no improvement in hours consider consulting Infectious Disease, ophthalmology, ENT and/or neurosurgery

16. Management
Obtain blood culture in younger patients or those that appear systemically ill
Culture ocular discharge
Obtain orbital, epidural absces or sinus fluid if patient requires surgery
Include a sepsis evaluation if the patient appears toxic or has neurologic involvement

17. Complications Local abscess formation Orbital cellulitis
Intracranial extension of infection (eg subdural empyema, intracerebral abscess, extradural abscess and meningitis)
Cavernous venous sinus thrombosis
Septic emboli of the optic nerve
Optic nerve ischemia (due to compression) may result in visual loss

18. Summary
Orbital cellulitis is an emergency that requires prompt diagnosis and evaluation by ophthalmology
Periorbital cellulitis and orbital cellulitis have distinct differences that can be elicited by careful history and physical examination
If the physical exam cannot be fully completed for any reason, radiologic imaging is required
Patients with systemic illness or evidence of orbital cellulitis or neurologic involvement require inpatient admission
Improvement should occur within hours with antibiotics

19. Questions
A 6 year old child is brought to the emergency department by his parents because of upper respiratory tract symptoms, a progressively swollen left eye, and altered mental status. He has been otherwise healthy and is fully immunized. Upon examination, he is difficult to arouse. Local signs include a markedly swollen left eye with proptosis. Eye movements are difficult to assess because of the boy’s poor neurologic status. He is febrile, but hemodynamically stable. The most likely pathogenesis is:
A. Acute bacterial meningitis, with secondary infection of the left orbit
B. Bacteremia causing both ocular and intracranial illness
C. Head trauma, with ocular and intraocular manifestations
D. Intracranial mass causing ocular and neurologic manifestations
E. Orbital cellulitis, with the neurologic complication of bacterial meningitis

20. Questions
A father calls your office to report that his 2 year old daughter has had nasal congestion and fever for the past 2 days. She received a nonprescription medication this morning, and today her right eye is “swollen shut”. When she arrives in your office, she is febrile but nontoxic. Her right eyelids are swollen and erythematous. It is nearly impossible to determine whether her extraocular movements are normal, but she exhibits increased tearing of the affected eye. Of the following, the most reasonable diagnosis and plan of treatment are:
A. Allergic reaction and trial of antihistamine at home
B. Periorbital cellulitis and IV antibiotics and CT scan of the orbits
C. Periorbital cellulitis and ophthalmology consultation and IV antibiotics
D. Periorbital cellulitis and oral antibiotics at home
E. Reactive periorbital swelling from sinusitis and nasal decongestant at home

21. References
Hauser, A and Fogarasi, S. Periorbital and Orbital Cellulitis. Pediatrics in Review. 2010;31: