Periorbital cellulitis

- Anatomy
o The orbital septum is a fibrous membrane that extends from the periosteum of the
orbit as the arcus marginalis and lies just deep to the orbicularis oculi muscle. In the
upper lids, the septum fuses with the levator aponeurosis. In the lower lids, the
septum fuses with the capsulopalpebral fascia.1 The orbital septum acts as a physical
barrier to the spread of infection

- Pathology
o In non-immunosed, young patient usually haemophilus influenza b usually after local
trauma to the skin including insect bites
o Should keep in mind that this bug can cause other infection e.g meningitis
 Should exclude meningism
o In older ppl, spread of infection from paranasal sinusitis or dental abscess

- When associated with trauma

o Staphylococcus aureus: This may include methicillin-resistant Staphylococcus
aureus18 and treatment should be tailored to local incidence of infection . 
o Streptococcus pyogenes (group A streptococci)
- In the absence of trauma
o Streptococcus pneumoniae
o H influenzae type b was the predominant cause prior to the advent of the Hib vaccine
but has now only been shown to cause rare cases.8,19,20,21

- Clinical features: -
o Fever, erythema, tenderness and oedema of eyelids
o Almost always unilateral
- Investigations
o CT scan to assess if there is posterior spread
o Lumbar puncture – to exclude meningitis
- Should be treated promptly
o Why to prevent spread to posterior spread –orbital cellulitis
 Proptosis
 Painful ocular movement
 Reduced visual acuity
Management

Preseptal cellulitis
12,6

 Adults: 250(qds) - 500(tds)mg oral co-amoxiclav depending on severity of infection, for 10

days with daily review until there is definite improvement (then every 2-7 days until
complete recovery).5
 Children: 20-40mg/kg/day oral co-amoxiclav over 24h in three divided doses.
 Lid abscesses should be drained.9

Orbital cellulitis
 Hospital admission under the joint care of the ophthalmologists and the ENT surgeons is
mandatory.3 (Prior to the advent of antibiotics, orbital cellulitis had a mortality rate of
17% and 20% of the survivors were blind in the affected eye. 1)
 These patients will have a full set of investigations (see above).
 Intramuscular - or more commonly - intravenous antibiotics are used (e.g. ceftriaxone 1-
4gm daily with 1-2gm flucloxacillin qds) in addition to metronidazole in patients over 10
years old with chronic sinonasal disease.5
 Clindamycin plus a quinolone such as ciprofloxacin are used where there is penicillin
sensitivity.13Vancomycin is also an alternative.
 Optic nerve function is monitored every 4 hours (pupillary reactions, visual acuity, colour
vision and light brightness appreciation).
 Treatment may be modified according to microbiology results and lasts for 7-10 days. 13
 Surgery is indicated where there is CT evidence of an orbital collection, where there is no
response to antibiotic treatment, where visual acuity decreases and where there is an
atypical picture which may warrant a diagnostic biopsy. Surgery often concurrently
warrants drainage of infected sinuses. 6

Complications

- Orbital cellulitis
- Cavernous sinus thrombosis
- Meningitis

Differential diagnosis

 Orbital pseudotumor, who are usually complaining only of eye pain.

 Angioedema
 Insect bites
 Nephrotic syndrome
 Orbital cellulitis