Periorbital (Preseptal) Cellulitis

Periorbital vs orbital cellulitis

The orbital septum separates the eyelid from the eye socket. Infection in front of it (periorbital) is usually mild; infection behind it (orbital cellulitis) can threaten vision and spread to the brain.

Causes

• Sinusitis: the most common source in children, especially ethmoid sinus infection
• skin breaks: insect bites, scratches, cuts, chickenpox lesions
• eyelid lesions: infected stye or chalazion
• Dacryocystitis: infection of the tear sac at the inner corner of the eye
• skin infections: impetigo
• upper respiratory infections and dental infections

Common bacteria include Staphylococcus aureus (including MRSA), Streptococcus pneumoniae and Streptococcus pyogenes. Haemophilus influenzae type b was once common but is now rare thanks to vaccination.

Symptoms

• redness and swelling of the upper and/or lower eyelid, usually one side
• warmth and tenderness
• the eye itself is usually white or only slightly red
• normal vision
• normal, painless eye movement
• fever and feeling unwell in some, particularly children

Diagnosis

A doctor diagnoses periorbital cellulitis by examining the eyelid and eye. The key checks are vision, pupil reactions, eye movements, whether the eye is bulging, and whether eye movement is painful.

• In young children, the eyelid may need to be gently opened to check the eye.
• CT scan of the orbits and sinuses is ordered if orbital cellulitis is suspected, if the eye cannot be examined, or if there is no improvement on antibiotics.
• Blood tests may be done in unwell children.

Treatment

• Oral antibiotics for 5 to 10 days in most adults and older children who are well. The choice covers staph and strep, and MRSA in areas where it is common.
• Intravenous antibiotics in hospital for babies under 1 year, children who are unwell or not drinking, those with severe swelling, or anyone who does not improve within 24 to 48 hours.
• Treat the source: sinusitis, styes, tear duct infection.
• Warm compresses to ease swelling.
• Pain relief: acetaminophen (paracetamol) or ibuprofen, following the label dose.
• Follow-up within 24 to 48 hours to check improvement.

Complications

Periorbital cellulitis rarely causes complications when treated, but it can occasionally progress to:

• orbital cellulitis
• an eyelid or orbital abscess
• spread of infection to the brain (meningitis or cavernous sinus thrombosis), very rarely

Outlook

Most people improve within 24 to 48 hours of starting antibiotics and recover fully within a week or two, without lasting effects on vision.

Prevention

• keep up to date with routine childhood vaccines, including Hib and pneumococcal vaccines
• keep children's nails short and discourage scratching bites
• clean cuts and scrapes near the eyes
• treat styes and sinus infections promptly

Frequently asked questions

What is periorbital cellulitis?

Periorbital cellulitis is a bacterial infection of the eyelid and surrounding skin that does not involve the eye socket. It causes a red, swollen, warm, tender eyelid with normal vision and eye movements, and usually clears with antibiotics.

How do you tell periorbital from orbital cellulitis?

In periorbital cellulitis, vision is normal and moving the eye does not hurt. Orbital cellulitis causes pain when moving the eye, double vision, a bulging eye and sometimes reduced vision. Orbital cellulitis is an emergency needing hospital treatment.

Is periorbital cellulitis serious?

It is usually not serious if treated promptly with antibiotics. However, it can occasionally spread to the eye socket. Seek emergency care if you notice pain on eye movement, a bulging eye, vision changes or severe headache.

How long does periorbital cellulitis take to heal?

Most people improve within 24 to 48 hours of starting antibiotics, and swelling resolves within about a week. Antibiotics are usually taken for 5 to 10 days. If swelling worsens after 48 hours, return to a doctor.

Is periorbital cellulitis contagious?

The condition itself is not contagious in the usual sense, but the bacteria causing it can spread through contact, for example from impetigo. Wash hands regularly and avoid sharing towels while it is being treated.