Periorbital (or preseptal) cellulitis, is an infective oedema of the eyelids and periorbital skin with no involvement of the orbit. Periorbital cellulitis is usually caused by Staphylococcus, streptococcus or Haemophilus bacteriae (more likely in unimmunised children).
Periorbital cellulitis can follow a minor injury to the eye. It can also occur following another infection, such as a cough or cold, where the infection spreads to the eye or following sinusitis. Periorbital cellulitis is infection of the eyelid skin anterior to the orbital septum. Orbital cellulitis is infection of the orbital tissues posterior to the orbital septum.
Very occasionally, periorbital cellulitis can progress to orbital cellulitis. This is more likely in children than adults, who are also harder to clinically assess. Orbital cellulitis (an infection of soft tissues in the orbit) is a surgical emergency with significant complications. These include loss of vision, abscess formation, venous sinus thrombosis and extension to intracranial infection with subdural empyema, and meningitis. This guide covers when to refer for hospital management.
Periorbital cellulitis is characterized by acute onset of:
If there is bilateral eyelid swelling, consider allergic conjunctivitis, especially if itchy and history of atopic conditions in personal or family background. In allergic conjunctivitis, the surrounding skin is usually a normal colour, whereas in an infective cause, the surrounding skin is erythematous.
Examination should include:
General physical examination, looking for signs of systemic involvement (temperature, perfusion, heart rate, lymphadenopathy)
Periorbital and orbital cellulitis are distinct clinical diseases. However, they have overlapping clinical features and therefore can be difficult to differentiate, especially in the early stages.
If any of the below are present, the alternative diagnosis of orbital cellulitis should be considered. The child must be referred urgently to hospital for assessment – this is for same day assessment via Kingston hospital switchboard (will be to PAU phone during normal working hours and registrar bleep out of hours)
Mild
Oral co-amoxiclav (clindamycin if penicillin allergic), and the course should usually be 7-10 days. Clinical improvement should occur over 24-48 hours and ideally, a plan should be made for re assessment after this time period.
Take into account:
– Social circumstances.
– Skills and confidence of carer to care for the child and to spot red flag symptoms.
– Distance to healthcare facility in case of deterioration.
If there is no improvement or deterioration after 24-48 hours of therapy, contact the Paediatric Assessment Unit for same day assessment (via switchboard).
Moderate-severe (or if any suspicion of orbital cellulitis)
Refer immediately to hospital if:
Please call on call paediatrics via switchboard to alert of referral – the child may be seen in the Paediatric Assessment Unit, or asked to attend A&E if they sound clinically very unwell as resuscitation facilities are more readily available there.
Hospital management may involve intravenous therapy (e.g. intravenous ceftriaxone until response is seen), and there is potential for this to be ambulatory if the child is well, examination is reassuring and social circumstances allow.
If there is a suspicion of orbital cellulitis, or physical examination is not reassuring, further investigations may include CT imaging of brain and orbits.
Ophthalmology input is often needed if IV therapy is initiated, and the child can be referred to the Royal Eye Unit for assessment from the paediatric department. Ophthalmology are also contactable via Kinesis and aim to reply to queries within 24 hours – there is a facility to attach photographs as needed. If there is suspicion of a foreign body or traumatic eye injury, please refer directly to Eye Casualty at the Royal Eye Unit for their assessment. Rather than a walk-in facility, the Royal Eye Unit are now offering booked urgent appointments to facilitate social distancing in their waiting room – the dedicated phone number for this is 020 8934 6799.
