Chapter XVII.7. Periorbital and Orbital Cellulitis
Kevin R. Card
June 2022

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A four-year-old previously healthy female presents to the emergency department (ED) with pain, swelling, and redness of her left eye which has been increasing in severity since yesterday morning. She has had some nasal congestion and some clear, watery nasal discharge for 6 days but had not been seen for these symptoms. There is no history of trauma, insect bite or stye. She started having a fever this afternoon which prompted mom to bring her to the ED.

Exam: VS T39.1, P110, R30, BP 90/50. She is visibly distressed. There is periorbital erythema and edema of her left eye. Visual acuity, pupillary response and extraocular movements are difficult to assess secondary to this swelling. Her right eye has full extraocular movements, pupil is reactive to light and her vision is intact. Palpation of the left cheek elicits pain.

CBC shows a WBC count of 21,000 per cubic mm. CT scan shows acute inflammation of the left extraocular muscles and fluid accumulation in the left ethmoid sinus. IV ceftriaxone and vancomycin are administered in the ED. She is admitted to the hospital and continued on IV antibiotics. Ophthalmology and otolaryngology are consulted.


Orbital and periorbital cellulitis refer to an infectious inflammation of the soft tissues of the orbit (1). They are classified based on which tissues of the orbit are affected, and present differently due to these anatomical differences. The crucial layer of the orbit to consider in cellulitis is the orbital septum (1,2). The orbital septum, also referred to the palpebral fascia, is the fibrous component of the eyelid and functions as the anterior supportive layer of the orbit and an anatomical border preventing lymphatic and venous flow between the two compartments it separates (2).

Periorbital cellulitis, also referred to as preseptal cellulitis, is an infection confined to the tissues anterior to the orbital septum without extension posterior to this layer (1-3). Periorbital cellulitis is many times more common than orbital cellulitis (1). It is more commonly seen in young children, and 84% to 87% of orbital tissue swelling has actually been attributed to periorbital cellulitis (2,4). Younger children tend to have greater success with conservative treatment and require surgery less commonly than older patients. Periorbital cellulitis is considered to be a contained infection and poses minimal risk for hematogenous spread (2). Common causes of periorbital cellulitis may include minor external trauma, which may be caused by cuts, superficial abrasions, and insect bites, as well as internal inflammatory processes, such as hordeolum, chalazion, erysipelas, and dacryocystitis (1-4).

Symptoms of periorbital cellulitis include swelling, erythema, and tenderness of the eyelids as well as potential conjunctival injection (4-7). Fever is possible and is more likely seen in young children (4,6,7). Other signs may include pain, warmth, and edema of the involved eyelid. Notably, visual acuity, mobility of the extraocular muscles, and pupillary reactivity are preserved in preseptal cellulitis and there is classically no pain with eye movement (5-7). It is very important to rule out a postorbital process by confirming that the patient is without proptosis, pain with eye movement, or changes to visual acuity (4,6,7). Presence of any of these signs suggest the possibility of orbital cellulitis and patients should receive confirmatory imaging as soon as possible (2,4-7). Proptosis can be difficult to confirm if the periorbital tissues are very swollen. Asking the patient to move their eyes around, even if the affected eye is difficult to view can be helpful since painful extraocular movements (EOMs) are suggestive of orbital cellulitis.

Cultures from conjunctiva and blood can be obtained, but the utility of this is low. This is because such surface cultures not reflect the etiology of the cellulitis and blood cultures will only be positive in patients with bacteremia or sepsis (7). For this reason, it is suggested to obtain blood cultures if a child is ill-appearing, toxic, or suspected to be septic (6,7). If meningitis is suspected, prompt lumbar puncture and analysis of CSF should be performed (6). Imaging with CT or MRI scanning may be necessary to confirm or rule out orbital cellulitis, if the patient does not respond to treatment, or if a subcutaneous abscess is suspected (4-7). Antibiotic selection is based on history and examination, but Staphylococcus aureus and Streptococcus species, usually Group A beta-hemolytic streptococci (GABHS), are the most common organisms in patients with eyelid cellulitis caused by trauma (4,6,7). A recently recommended course for hospitalized patients is ampicillin-sulbactam or IV clindamycin plus cefotaxime or ceftriaxone, with the addition of metronidazole if intracranial extension is expected. However, in order to provide complete coverage of Staphylococcus aureus in serious infections such, vancomycin or linezolid should be used (6,8).

Children, teenagers, and adults diagnosed with preseptal cellulitis can be treated with oral antibiotics and followed in the outpatient setting so long as the case is not severe (4). Haemophilus influenzae type B (HiB) was formerly a considerable cause of preseptal cellulitis in infants and children, especially since this was frequently accompanied by septicemia and meningitis. For this reason all febrile children with preseptal cellulitis used to be hospitalized and treated with IV antibiotics. Fortunately, the HiB vaccine has virtually eliminated this pathogen and made such cases extremely unlikely (4,6,7). Cellulitis with Group A Streptococcus and Staphylococcus aureus are less likely to cause septicemia, thus patients today can usually be treated as outpatients. Some sources recommend amoxicillin-clavulanic acid for these patients, but options such as combinations of trimethoprim-sulfamethoxazole, clindamycin, doxycycline, and cephalosporins would have a greater efficacy against more strains of Staphylococcus aureus and Streptococcal species, and are therefore appropriate when considering local bacterial antibiotic sensitivity patterns. Since MRSA is frequently involved, clindamycin or an alternate anti-MRSA antibiotic should be employed (8,9).

Orbital cellulitis is an infection that is not confined by the orbital septum and extends posterior to the orbital septum (1-7). Orbital cellulitis is more severe than preorbital cellulitis, but is less common (1). It is more common in children than adults, with incidences of 1.6 to 6 per 100,000 children and 0.6 to 2.4 per 100,000 adults (3). Orbital cellulitis most commonly occurs secondary to rhinosinusitis of the ipsilateral ethmoid sinus, but may also occur after orbital surgery, after trauma to the orbit, dacryocystitis, or via other local or systemic spreading of infection (2,5).

The increased incidence in children has several potential explanations. Firstly, children’s bony sinus separating the sinuses from the orbit are thinner than adults, limiting the function as a protective barrier. Children also have skull sutures and more porous bones than adults, increasing the potential for local pathogenic invasion. It is also thought that the larger vascular foramina in children increases the potential for hematogenous spread (6).

Signs of orbital cellulitis may overlap considerably with signs of preseptal cellulitis; however orbital cellulitis is characterized by proptosis, restricted ocular motility, decrease in visual acuity, abnormal pupillary reaction, and/or pain with eye movement (4-7). CBC may show a leukocytosis. If meningitis is suspected IV antibiotics should be administered immediately and a lumbar puncture should be performed(6). Imaging with CT scan or MRI in these patients is recommended to determine the extent of the orbital cellulitis as well as to identify a possible subperiosteal abscess (4,5). These imaging modalities also help to detect potential infections extending from periorbital sites (4,7). Some possible causes of infections extending from periorbital regions include infection of the paranasal sinuses, dental infections, and trauma with retained foreign bodies (5). Draining of any abscesses may be necessary, and otolaryngology consultation should be sought if sinusitis is present to consider draining the sinuses (2,7).

It is appropriate for these patients to be hospitalized for a course of IV antibiotics. Ophthalmology and otolaryngology should be consulted for orbital cellulitis to assess the extent of orbital extension and if surgery is needed. The most common pathogens include Staphylococcus aureus, Streptococcal species, and anaerobes (6). The current recommended regimen is vancomycin plus ceftriaxone, with the addition of metronidazole to cover anaerobes (3,6). A recent study explored the addition of corticosteroids in conjunction with antibiotics. Although the patients with corticosteroids plus antibiotics required less time on antibiotics and had resolution of symptoms sooner, there was no effect on length of hospitalization. This data was also limited to one study with a population of 21 patients, so more research is required before a formal recommendation can be made regarding the addition of corticosteroids to IV antibiotics (4). Although IV antibiotics are sufficient to treat orbital cellulitis in most cases, surgical management of an abscess or resistant infection may be necessary in severe cases. Prompt, aggressive treatment is crucial since orbital cellulitis is far more likely than periorbital cellulitis to spread hematogenously and cause sepsis (4,7). Complications of orbital cellulitis include meningitis, sepsis, and cavernous sinus thrombosis (6,7).


Questions
1. The population most commonly affected by orbital cellulitis is:
   a. Infants and young children
   b. Teenagers
   c. Adults
   d. Elderly

2. Common causes of periorbital cellulitis include the following (select all that apply):
   a. Sinusitis
   b. Chalazion
   c. Dental infection
   d. Eyelid skin laceration

3. Which of the following symptom provides the most significant indication for advanced imaging studies (CT or MRI scanning)?
   a. Erythema
   b. Pain looking left and right
   c. Warmth around the orbit
   d. Identifiable insect bite just lateral to area of swelling

4. A 12-year-old patient returns to the office 3 days after being diagnosed with preseptal cellulitis for persistence of symptoms. She was started on amoxicillin-clavulanic acid. Her symptoms have not improved but have not worsened. There is no pain or restriction of EOM, no change in visual acuity, and no proptosis. What is the likely pathogen responsible?

5. Name 3 potential severe complications of orbital cellulitis that are not likely to occur secondary to preseptal cellulitis.

6. T/F: The most common pathogens responsible for cellulitis in general are the same as that for preseptal cellulitis.


References
1. Santos JC, Pinto S, Ferreira S, et al. Pediatric preseptal and orbital cellulitis: A 10-year experience. Int J Pediatr Otorhinolaryngol. 2019;120:82-88.
2. Wong SJ, Levi J. Management of pediatric orbital cellulitis: A systematic review. Int J Pediatr Otorhinolaryngol. 2018;110:123-129.
3. Kornelsen E, Mahant S, Parkin P, et al. Corticosteroids for periorbital and orbital cellulitis. Cochrane Database Syst Rev. 2021;4(4):CD013535.
4. Williams KJ, Allen RC. Paediatric orbital and periorbital infections. Curr Opin Ophthalmol. 2019 Sep;30(5):349-355.
5. Gervasion KA, Peck TJ. Chapter 7.3. Infectious Orbital Disease. In: Gervasion KA, Peck TJ (eds). The Wills Eye Manual, 8th edition. 2021. Lippincott Williams and Wilkins, Philadelphia. pp. 162-168.
6. Olitsky SE, Marsh JD, Jackson MA. Chapter 652. Orbital Infections. In: Kliegman RM, St. Geme JW, Blum NJ, et al (eds). Nelson’s Textbook of Pediatrics, 21st edition. 2019. Elsevier, Philadelphia. pp. 3391-3393.
7. Tsirouki T, Dastiridou AI, Flores NI, et al. Orbital Cellulitis. Surv of Ophthalmol. 2018;63(4):534-553.
8. Elsevier Clinical Care Overview. Methicillin-Resistant Staphylococcus Infections (MRSA and MRSE). April 2022. https://www-clinicalkey-com.eres.library.manoa.hawaii.edu/#!/content/clinical_overview/67-s2.0-3d726a69-768b-4945-ac76-05416c7050dd#references. Accessed June 2022
9. Gervasion KA, Peck TJ. Chapter 6.10. Preseptal Cellulitis. In: Gervasion KA, Peck TJ, (eds). The Wills Eye Manual, 8th edition. 2021. Lippincott Williams and Wilkins, Philadelphia. pp: 147-150.


Answers to questions
1. a. Infants and young children have the highest rate of occurrence of orbital cellulitis.
2. All of the above. Although a skin laceration is easily diagnosed, a sinusitis needs to be confirmed with a CT or MRI scan. A chalazion is usually diagnosed by history or a fluctuant skin mass in the eyelid. A dental infection involving the upper teeth can easily spread itself into the orbit.
3. b. Pain with movement of the eye suggests involvement of tissue posterior to the orbital septum, raising concern for orbital cellulitis. This must be followed by advanced imaging studies (CT or MRI).
4. Since this patient was prescribed amoxicillin-clavulanic acid and not clindamycin, it is possible that this patient is experiencing a preseptal cellulitis caused by resistant MRSA. Clindamycin does not cover all MRSA either. Better MRSA coverage is achieved with doxycycline, vancomycin, linezolid.
5. Meningitis, sepsis, and cavernous sinus thrombosis are potential complications of orbital cellulitis. The risk of these severe secondary manifestations of the infection are why aggressive management of orbital cellulitis is so crucial.
6. True. Staphylococcus aureus and Streptococcus species are the most common pathogens responsible for preseptal cellulitis as well as cellulitis found elsewhere on the body!


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