ConditionEyes & vision
Orbital Cellulitis
Orbital cellulitis is an infection of the fat and muscles around the eye, behind the orbital septum, the thin membrane that separates the eyelid from the eye socket. It most often spreads from sinusitis, especially in children. Signs include a swollen, red eyelid with pain on moving the eye, a bulging eye, double vision or reduced vision, and fever. It is a medical emergency that can cause blindness, meningitis or brain abscess, and needs IV antibiotics and sometimes surgery.
Also called: Postseptal cellulitis, eye socket infection, orbital infection
At a glance
- What it is
- Infection behind the orbital septum, in the eye socket.
- Main cause
- Spread from sinusitis, especially the ethmoid sinuses. Also injury, dental infection, eyelid infections.
- Key signs
- Pain with eye movement, limited eye movement, bulging eye, double or reduced vision, fever.
- Diagnosis
- Examination and CT scan of the orbits and sinuses.
- Treatment
- Hospital admission, IV antibiotics, and surgical drainage of abscesses if needed.
- Complications
- Vision loss, cavernous sinus thrombosis, meningitis, brain abscess.
When to get help
Call 911 or go to the ER
- A swollen, red eyelid with pain on moving the eye, the eye bulging forward, double vision or reduced vision
- Eye swelling with fever and headache, confusion, stiff neck or drowsiness
- Swelling spreading to both eyes, or a child who is very unwell with eye swelling
See a doctor within a day or two
- A red, swollen eyelid with fever in a child, even if the eye moves normally and vision is fine
- Eyelid swelling during or after sinusitis or a cold
- Eyelid swelling that is worsening despite oral antibiotics after 24 to 48 hours
Book a routine appointment
- Mild, recurrent eyelid swelling without pain or fever
How orbital cellulitis develops
The eye socket (orbit) shares thin bony walls with the sinuses, especially the ethmoid sinuses between the eyes. Infection can pass through these walls or through veins without valves that connect the face, sinuses and orbit. The orbital septum normally acts as a barrier. Infection in front of it, limited to the eyelid, is preseptal (periorbital) cellulitis. Infection behind it is orbital cellulitis, which is much more dangerous.
Causes and risk factors
- Sinusitis: the cause in most cases, particularly in children
- eyelid or facial infections: styes, insect bites, impetigo
- injury: penetrating eye socket trauma or fractures
- dental infections of the upper teeth
- dacryocystitis: infection of the tear sac
- after eye or sinus surgery
- higher risk in children, people with diabetes and weakened immunity
Common bacteria include Streptococcus species, Staphylococcus aureus (including MRSA) and Haemophilus influenzae in unvaccinated children. Fungal infection (mucormycosis) is a rare, aggressive cause in people with uncontrolled diabetes or immune suppression.
Symptoms
- swollen, red or purple eyelids, usually on one side
- pain on moving the eye
- limited eye movement
- bulging of the eye (proptosis)
- double vision
- reduced vision or color vision
- fever and feeling unwell
- redness and swelling of the white of the eye (chemosis)
- headache and nasal symptoms from sinusitis
Orbital vs preseptal cellulitis
| Preseptal (periorbital) | Orbital | |
|---|---|---|
| Location | Eyelid, in front of the septum | Eye socket, behind the septum |
| Eye movement | Normal and painless | Painful and limited |
| Bulging eye | No | Often |
| Vision | Normal | May be reduced |
| Severity | Usually mild, often treated with oral antibiotics | Emergency, needs IV antibiotics and hospital care |
Swollen eyelids can make it hard to judge eye movement in children, so imaging is used when there is doubt.
Diagnosis
- examination of vision, pupils, eye movements, color vision and eye pressure
- CT scan of the orbits and sinuses with contrast, to confirm orbital involvement and look for an abscess
- MRI if intracranial complications or cavernous sinus thrombosis are suspected
- blood tests and blood cultures
- urgent assessment by ophthalmology and ENT specialists
Treatment
- Hospital admission with frequent checks of vision and eye movement
- IV antibiotics covering likely bacteria, including MRSA where common, usually for several days, then oral antibiotics for a total of 2 to 3 weeks
- Nasal decongestants and saline to help drain the sinuses
- Surgery to drain an orbital or subperiosteal abscess, or the infected sinuses, if vision is threatened, the abscess is large, or there is no improvement within 24 to 48 hours
- Steroids are sometimes added once infection is controlled to reduce swelling
- Antifungal treatment and surgery for fungal infection
Complications
- permanent vision loss from pressure on the optic nerve
- cavernous sinus thrombosis: a blood clot in veins behind the eye
- meningitis
- brain abscess
- spread of infection to the bone
Outlook
With prompt IV antibiotics, and surgery when needed, most people recover fully with normal vision. Delays in treatment increase the risk of vision loss and life-threatening complications.
Frequently asked questions
What are the symptoms of orbital cellulitis?
Symptoms include a swollen, red eyelid, pain when moving the eye, limited eye movement, a bulging eye, double or blurred vision, and fever. These signs mean the infection has spread behind the eye and need emergency care.
What is the difference between orbital and periorbital cellulitis?
Periorbital (preseptal) cellulitis affects only the eyelid in front of the orbital septum, with normal eye movement and vision. Orbital cellulitis involves the eye socket behind the septum, causing painful or limited eye movement, bulging and vision changes. Orbital cellulitis is far more serious.
What causes orbital cellulitis in children?
In children, it is most often caused by bacterial sinusitis spreading from the ethmoid sinuses into the eye socket. It may follow a cold. Less often, it results from eyelid infections, insect bites, injury or dental infection.
How is orbital cellulitis treated?
It is treated in the hospital with IV antibiotics. Doctors check vision and eye movement frequently. Surgery is needed to drain an abscess or infected sinuses if vision is threatened or the infection does not improve within a day or two.
Can orbital cellulitis cause blindness?
Yes. Untreated or severe orbital cellulitis can damage the optic nerve and cause permanent vision loss. Prompt diagnosis and treatment make this uncommon.
Sources
This guide was written from current patient and clinical guidance, including:
- American Academy of Ophthalmology: Orbital Cellulitis (EyeWiki)
- American Academy of Pediatrics: Red Book, Orbital and Periorbital Cellulitis
- MedlinePlus: Orbital cellulitis
- NHS: Cellulitis
- American Academy of Otolaryngology-Head and Neck Surgery: Complications of sinusitis