Periorbital Cellulitis: Overview

Simeon Harrow

Introduction

Periorbital cellulitis is an infection affecting the eyelid and the surrounding area of the eye (1), anterior to the orbital septum (2). Periorbital cellulitis presents very similarly to orbital cellulitis, which is an infection affecting the eye and deeper structures posterior to the orbital septum (1,2). Periorbital cellulitis typically results from the spread of infection following sinusitis (2) or local trauma to the skin around the eye causing infection; from an insect bite or scratch. Orbital cellulitis is often due to the progression of periorbital cellulitis or injury to the eyeball (1).  

Epidemiology

Periorbital cellulitis can present in individuals of all ages, however is usually reported in the paediatric age group. Periorbital cellulitis presents more frequently than orbital cellulitis (2).

Basic Anatomy of the Orbit

The orbit is bordered by the paranasal sinuses; the maxillary sinus is located inferiorly, the ethmoid sinus is located medially and the frontal sinus is located superiorly (2). The ethmoid sinus is separated from the orbit by a paper-thin bone plate called the lamina papyracea (2,3). Infection arising particularly from the ethmoid sinus can easily spread to the orbit (2).

Pathophysiology

The most common isolated bacteria associated with periorbital cellulitis are Haemophilus, Staphylococcus and Streptococcus species (3). However, the introduction of Haemophilus influenza B (Hib) vaccination has greatly reduced the prevalence Hib infection (4). Less reported infectious causes include Pseudomonas, Neisseria, Acinetobacter, Bacillus, Proteus, Mycobacterium, Pasteurella and Nocardia (2).

The most common bacterial pathogens resulting in acute sinus infection are Streptococcus pyogenes, Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. Whereas chronic rhinosinusitis often results from Staphylococcus aureus infection (5).

Furthermore, sinus infection may progress and spread via the lamina papyracea to the orbit, leading to periorbital or orbital cellulitis (2). 

Presentation

Periorbital cellulitis presents similarly to orbital cellulitis; with erythema, swelling, pain or fever. However, periorbital cellulitis does not typically result in restricted or painful eye movements and visual examination is normal. In contrast, orbital cellulitis may lead to visual impairment, proptosis and painful or restricted eye movements (1).

Diagnosis

Diagnosis of periorbital cellulitis primarily involves focused history taking, to identify a possible source of infection; insect bite, injury or report of sinusitis. Clinical examination is crucial in noting surrounding erythema and swelling, as well as assessing visual acuity and eye movements. Notably, periorbital cellulitis does not typically result in reduced visual acuity or restricted and painful eye movements. Furthermore, blood tests may be requested to review inflammatory markers and computed tomography (CT) imaging may be considered, where the diagnosis between periorbital and orbital cellulitis remains uncertain (2), or to further evaluate suspected orbital cellulitis (6).

Management

The management of periorbital cellulitis with mild symptoms usually consists of oral antibiotics according to local guidelines, against commonly associated bacterial infections. Cases of periorbital cellulitis usually improves rapidly following initiation of antibiotics. However, if no improvement is reported after 24 to 48 hours, patients should be reviewed in hospital by an ophthalmologist, commenced on broad-spectrum antibiotic therapy and undergo further investigation with CT imaging (2). Furthermore, orbital cellulitis is usually managed with intravenous antibiotics and review for surgical intervention (6).

References

  1. Baiu, I. and Melendez, E., 2020. Periorbital and orbital cellulitis. JAMA, 323(2), pp.196-196.
  2. Bae, C. and Bourget, D., 2023. Periorbital cellulitis. In StatPearls [Internet]. StatPearls Publishing.
  3. Carlisle RT, Digiovanni J. Differential diagnosis of the swollen red eyelid. American family physician. 2015 Jul 15;92(2):106-12.
  4. Ambati BK, Ambati J, Azar N, Stratton L, Schmidt EV. Periorbital and orbital cellulitis before and after the advent of Haemophilus influenzae type B vaccination. Ophthalmology. 2000 Aug 1;107(8):1450-3.
  5. Brook I. Microbiology of chronic rhinosinusitis. European Journal of Clinical Microbiology & Infectious Diseases. 2016 Jul;35:1059-68.
  6. Yadalla, D., Jayagayathri, R., Padmanaban, K., Ramasamy, R., Rammohan, R., Nisar, S.P., Rangarajan, V. and Menon, V., 2023. Bacterial orbital cellulitis–A review. Indian Journal of Ophthalmology, 71(7), pp.2687-2693.

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