Version 7 (xy.02.10)
Condition / Cellulitis: preseptal and orbitalAetiology / 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
Predisposing factors / 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
Symptoms / 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
Signs / 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
pupil reactions may be abnormal (RAPD)
pyrexia
Feature / Preseptal cellulitis / Orbital cellulitis
proptosis / absent / present
Ocular motility / normal / painful, restricted
Visual acuity / normal / reduced
RAPD / normal / present
(Modified from a table in Denniston AKO and Murray PI: Oxford Handbook of Ophthalmology. OUP 2008)
Differential diagnosis / Preseptal cellulitis:
orbital cellulitis
hordeolum (external or internal)
acute blepharitis
viral conjunctivitis with eyelid swelling
allergic conjunctivitis with eyelid swelling
Added by Wendy Franks: consider angioneurotic oedema if bilateral - this could be fora presentation of a life threatening allergic episode in a child -eg peanut allergy or bees sting.Thinking of insects - if unilateral - look for skin lesions such as insect bites.
Orbital cellulitis:
cavernous sinus thrombosis
mucormycosis (fungal infection)
sarcoidosis
dysthyroid exophthalmos
neoplasia with inflammation
Management by Optometrist
Non-pharmacological / Check and record patient’s temperature
Preseptal cellulitis: cold compress for symptomatic relief
Pharmacological / Preseptal cellulitis: analgesia as required
Management
category / Preseptal cellulitis:
A2: initial management and emergency referral to Ophthalmologist. Telephone on-call Ophthalmologist
Orbital cellulitis:
A1: emergency referral to Ophthalmologist, no intervention. Telephone on-call Ophthalmologist
Possible management by Ophthalmologist
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
admission to hospital
systemic antibiotics (parenteral and/or oral)
drainage of orbital abscess
co-management with ENT specialist colleague
Evidence base