Download Cellulitis, preseptal and orbital

CLINICAL MANAGEMENT GUIDELINES
Cellulitis, preseptal and orbital
Aetiology
Predisposing factors
Symptoms
Signs
Infections of the periorbital and orbital tissues range in severity, from
relatively minor to potentially life-threatening. These infections occur
most commonly in children under the age of 10 years
Preseptal cellulitis
 bacterial infection of tissues lying anterior to the orbital septum
(therefore not an orbital condition)
 in young children, high risk of extension into the orbit
Orbital cellulitis
 bacterial infection of tissues lying posterior to the orbital septum
(within the orbit)
 severe sight- and life-threatening emergency
For both conditions, the usual causative organisms are Staphylococcus,
Streptococcus and Haemophilus species
Preseptal cellulitis:
 upper respiratory tract infection
 dacryocystitis
 hordeolum
 impetigo (skin infection)
 insect bite or sting
 trauma, sharp or blunt, around eye
 recent surgery around eye
Orbital cellulitis:
 acute sinusitis (especially ethmoid sinusitis)
 trauma
 dacryocystitis
 preseptal cellulitis
 dental abscess
Preseptal cellulitis:
 acute onset of swelling, redness and tenderness of lids
 fever
 malaise
 irritability in children
Orbital cellulitis:
 sudden onset of unilateral swelling of conjunctiva and lids
 pain on ocular movement
 blurred vision and reduced visual acuity
 diplopia
 fever
 severe malaise
Preseptal cellulitis:
 erythema of skin (can extend beyond orbital rim)
 lid oedema, warmth, tenderness
 ptosis
 pyrexia (fever greater than 38°C, normal temperature ranges
from 36-37.5°C)
Orbital cellulitis:
 proptosis
 restriction of extraocular motility
 pain with eye movement
 visual acuity may be reduced
Cellulitis, preseptal and orbital
Version 10, Page 1 of 3
Date of search 13.02.15; Date of revision 27.05.15; Date of publication 06.08.15; Date for review 12.02.17
© College of Optometrists
CLINICAL MANAGEMENT GUIDELINES
Cellulitis, preseptal and orbital
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pupil reactions may be abnormal (RAPD)
pyrexia
Distinguishing between preseptal cellulitis and orbital cellulitis can be
difficult based on clinical observations alone (especially in children)
although the following table may be helpful for differential diagnosis:
Feature
Proptosis
Ocular motility
Visual acuity
Colour vision
RAPD
Preseptal cellulitis
absent
normal
normal
normal
normal
Orbital cellulitis
present
painful, restricted
reduced in severe cases
reduced in severe cases
present in severe cases
(Modified from a table in Denniston AKO and Murray PI: Oxford Handbook of
Ophthalmology, 3rd edition, OUP 2014)
Differential diagnosis
Preseptal cellulitis:
 orbital cellulitis
 hordeolum (external or internal)
 acute blepharitis
 viral conjunctivitis with eyelid swelling
 allergic conjunctivitis with eyelid swelling
 angioneurotic oedema (if bilateral): could indicate severe
systemic allergic reaction, e.g. in peanut allergy
 insect bite or sting (if unilateral): look for skin lesion(s)
Orbital cellulitis:
 cavernous sinus thrombosis
 mucormycosis (fungal infection)
 sarcoidosis
 dysthyroid exophthalmos
 neoplasia with inflammation
Management by Optometrist
Practitioners should recognise their limitations and where necessary seek further advice or refer
the patient elsewhere
Non pharmacological
None
Pharmacological
None
Management Category Preseptal and orbital cellulitis:
A1: emergency (same day) referral to ophthalmologist or A&E
Department, no intervention
Possible management by Ophthalmologist
Management of orbital infections typically involves a multi-disciplinary
approach (ophthalmology, ENT, paediatrics)
Preseptal cellulitis:
 confirmation of diagnosis
 CT or MRI scan
 children may require admission to hospital for observation
 systemic antibiotics (oral and/or parenteral)
Orbital cellulitis:
 confirmation of diagnosis
 CT or MRI scan
 blood tests, possibly including microbial culture
Cellulitis, preseptal and orbital
Version 10, Page 2 of 3
Date of search 13.02.15; Date of revision 27.05.15; Date of publication 06.08.15; Date for review 12.02.17
© College of Optometrists
CLINICAL MANAGEMENT GUIDELINES
Cellulitis, preseptal and orbital
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admission to hospital
systemic antibiotics (parenteral and/or oral)
drainage of orbital abscess
co-management with ENT specialist colleague
Evidence base
*GRADE: Grading of Recommendations Assessment, Development and
Evaluation (see http://gradeworkinggroup.org/toolbox/index.htm)
Sources of evidence
Baring DE, Hilmi OJ. An evidence based review of periorbital cellulitis.
Clin Otolaryngol. 2011;36(1):57-64
Nageswaran S, Woods CR, Benjamin DK Jr, Givner LB, Shetty AK.
Orbital cellulitis in children. Pediatr Infect Dis J. 2006;25(8):695-9
Botting AM, McIntosh D, Mahadevan M. Paediatric pre- and post-septal
peri-orbital infections are different diseases. A retrospective review of
262 cases. Int J Pediatr Otorhinolaryngol 2008; 72(3): 377-83
Georgakopoulos CD, Eliopoulou MI, Stasinos S, Exarchou A,
Pharmakakis N, Varvarigou A. Periorbital and orbital cellulitis: a 10-year
review of hospitalized children. Eur J Ophthalmol. 2010;20(6):1066-72
Upile NS, Munir N, Leong SC, Swift AC. Who should manage acute
periorbital cellulitis in children? Int J Pediatr Otorhinolaryngol.
2012;76(8):1073-7
LAY SUMMARY
Cellulitis means inflammation of the soft tissues, often due to infection. Preseptal and orbital
cellulitis are infections, of the soft tissues in the socket that surrounds the eye, usually caused by
common bacteria. They may follow a cold, sinusitis, an infection of the eyelid such as a stye, an
infection of the tear drainage channels, or injury or recent surgery near the eye. It is important to
try to distinguish between these two forms of cellulitis. Preseptal cellulitis is usually mild, except in
young children, but orbital cellulitis can result in generalised infection which can be a lifethreatening emergency. All cases need emergency referral to the ophthalmologist or to an
Accident and Emergency Department. Most will need to be admitted to hospital for tests and
antibiotic treatment and a number of different specialists may be involved: ophthalmologists, ear,
nose and throat specialists, and paediatricians (children’s doctors).
Cellulitis, preseptal and orbital
Version 10, Page 3 of 3
Date of search 13.02.15; Date of revision 27.05.15; Date of publication 06.08.15; Date for review 12.02.17
© College of Optometrists