Periorbital cellulitis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyed Arash Javadmoosavi, MD[2]

Synonyms and keywords: Preseptal cellulitis

Overview

Periorbital cellulitis is an inflammation and infection of the eyelid and area around the eye. Periorbital cellulitis is also called preseptal cellulitis because it affects the structures in front of the septum, such as the eyelid and skin around the eye. Periorbital cellulitis often occurs from a scratch or insect bite around the eye that leads to infection of the skin. Symptoms can include swelling, redness, pain, and tenderness to touch occurring around one eye only. The affected person is able to move the eye in all directions without pain, but there can be difficulty opening the eyelid, often due to swelling. Also vision is normal.

Characteristics

• Periorbital cellulitis must be differentiated from orbital cellulitis, which is an infection involving the soft tissues posterior to the orbital septum, including the fat and muscle within the bony orbit ant it is an emergency and sight-threatening situation. In contrast to orbital cellulitis, patients with periorbital cellulitis do not have bulging of the eye (proptosis), limited eye movement (ophthalmoplegia), pain on eye movement, and loss of vision. If any of these features is present, one must assume that the patient has orbital cellulitis and begin treatment with IV antibiotics. CT scan may be done to delineate the extension of the infection.

• Both periorbital cellulitis and orbital cellulitis occur more commonly in children and can present with eyelid inflammation, and distinguishing between the two conditions may be challenging. Hence, the evaluation should include a comprehensive ophthalmic examination, including an assessment of visual acuity, pupillary response, tonometry, anterior segment biomicroscopy, and ophthalmoscopy. A physical examination, including an assessment of routine vital signs, should be performed. Blood cultures should be obtained in patients with concern for systemic toxicity.

• A common cause of preseptal cellulitis is extension of infection from the paranasal sinuses, sinusitis. Other causes include trauma, foreign bodies, insect bites, skin infections (impetigo), eyelid lesions (chalazia, hordeola), and iatrogenic causes such as eyelid and oral procedures.

Causes

The most common bacterial germs causing periorbital cellulitis are Staphylococcus aureus, Streptococcus pneumoniae, and Streptococcus pyogenes. With increased vaccination, there are fewer cases of Haemophilus influenzae as a causative organism. Less common causes are Acinetobacter, Nocardia, Pseudomonas, Neisseria, Mycobacterium and fungal infections.

Epidemiology and Demographics

• Periorbital cellulitis can occur at any age, but it is common in children and it is more common than orbital cellulitis in this population.

Treatment

• The treatment of periorbital cellulitis differs based on the severity of disease and age of the patient. The mainstay of treatment is usually antibiotic coverage against staphylococcus aureus, the streptococcus species, and anaerobes. Patients who are over one year of age with mild symptoms can be treated as an outpatient with oral antibiotics. However, if the patient does not respond to oral antibiotics in 48 hours or if extension of the infectious process into the orbit is suspected, he or she should be admitted to the hospital and a CT scan must be performed to evaluate for orbital extension, and intravenous antibiotics must be indicated. Those with more severe disease or are less than one year of age, should be admitted to the hospital.

• Usually children under 2 years of age or febrile patients with a severe cellulitis are managed with intravenous antibiotics during hospitalization, with close followup. Hospitalization is also recommended in patients who cannot be followed up as outpatients. Intravenous antibiotics are usually indicated for two or three days, depending on improvement. If the condition improves, treatment can be switched to the appropriate oral antibiotics based on cultures.

Antimicrobial Regimens

• Periocular infection

• 1. Causative pathogens

• Streptococcus spp.
• Methicillin-sensitive Staphylococcus aureus (MSSA)
• Methicillin-resistant Staphylococcus aureus (MRSA)
• Hemophilus influenzae

• 2. Empiric antimicrobial therapy

• Preferred regimen (1): Clindamycin 300-450 mg PO q6h for 1-2 weeks or Clindamycin 600-900 mg IV q8h for 1-2 weeks
• Preferred regimen (2): Daptomycin 4 mg/kg IV qd for 1-2 weeks
• Alternative regimen (1): Trimethoprim/Sulfamethoxazole 160 mg PO q12h for 1-2 weeks or Trimethoprim/Sulfamethoxazole 2.5 mgkg IV q12h for 1-2 weeks
• Alternative regimen (2): Doxycycline 100 mg IV or PO q12h for 1-2 weeks
• Alternative regimen (3): Linezolid 600 mg IV or PO q12h for 1-2 weeks
• Alternative regimen (4): Vancomycin 1 g IV q12h for 1-2 weeks

• 3. Pathogen-directed antimicrobial therapy

• 3.1 Methicillin-resistant Staphylococcus aureus

• Preferred regimen (1): Vancomycin 1 g IV q12h for 1-2 weeks

• 3.2 Non-MRSA organisms

• Preferred regimen (1): Clindamycin 300-450 mg PO q6h for 1-2 weeks OR Clindamycin 600-900 mg IV q8h for 1-2 weeks
• Preferred regimen (2): Daptomycin 4 mg/kg IV qd for 1-2 weeks
• Alternative regimen (1): Trimethoprim/Sulfamethoxazole 160 mg PO q12h for 1-2 weeks OR Trimethoprim/Sulfamethoxazole 2.5 mgkg IV q12h for 1-2 weeks
• Alternative regimen (2): Doxycycline 100 mg IV or PO q12h for 1-2 weeks
• Alternative regimen (3): Linezolid 600 mg IV or PO q12h for 1-2 weeks

See also

• Orbital cellulitis

References

Donahue S, Schwartz G (1998). "Preseptal and orbital cellulitis in childhood. A changing microbiologic spectrum". Ophthalmology. 105 (10): 1902–5, discussion 1905-6. PMID 9787362.

External links

• Merck

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