Periorbital cellulitis

Related Terms

Antibiotics, antifungals, bacteria, bacterial infection, bacterial meningitis, blood clot, bug bites, cellulitis, conjunctivitis, ethmoid, ethmoid bone, eyelid, eyes, eye socket, fat tissue, fungus, Haemophilus influenzae B, HiB vaccine, hordeolum, infection, inflamed eye, inflammation, lacriminal, meningitis, muscle tissue, nasal cavity, nose, ophthalmologist, ophthalmology, orbit, para-nasal, periorbital, pinkeye, preseptal, secondary infection, sinus cavity, sinus infection, sinuses, sinusitis, stye, soft tissue, swelling, vaccine, vision loss.

Background

Cellulitis is an infection of soft tissues (like fat and muscle tissue). It can occur in any soft tissue, anywhere in the body.
When cellulitis affects the eyes, it is called ocular cellulitis. There are two forms of ocular cellulitis - periorbital and orbital. Both of these conditions usually begin with swelling or inflammation of one eye, which may or may not spread to the other eye.
Periorbital cellulitis, or preseptal cellulitis, is an infection of the soft tissues surrounding the eye. It is usually caused by an infection, such as conjunctivitis (pinkeye), which spreads from the membrane covering the outer part of the eye or from a bacterial infection of the nose or sinuses. Periorbital cellulitis, which accounts for 85-90% of all ocular cellulitis cases, is most prevalent among children under the age of five. Periorbital cellulitis cannot progress to orbital cellulitis because the septum serves as a protective fibrous barrier for the orbit (eye socket).
Orbital cellulitis is an infection of the soft tissue in the eye socket. The disease starts in the ethmoid sinus and the infection spreads into the subperiosteal lining of the orbit through the ethmoid bone. This form is considered more serious than periorbital cellulitis because it can cause permanent damage eye damage. In severe cases the infection can spread to the optic nerve, causing impaired vision. Orbital cellulitis is responsible for the remaining 10-15% of ocular cellulitis cases. This form is most common in children over the age of five.
The incidence of severe orbital cellulitis has decreased steadily since the introduction of HiB vaccine (Haemophilus influenzae type B). H. influenzae is a widespread bacteria that is present in about 75% of people. However, individuals who have healthy immune systems do not experience symptoms of the disease. Therefore, children (up to 12 months old) and individuals who have compromised immune systems typically experience the most benefit from the vaccine. The patient receives one immunization, administered intravenously, during his/her lifetime.

Author information

This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography

American Family Physician. Distinguishing Periorbital from Orbital Cellulitis. .
Canadian Ophthalmological Society. Periorbital Cellulitis. .
Natural Standard: The Authority on Integrative Medicine. .
Schramm VL Jr, Curtin HD, Kennerdell JS. Evaluation of orbital cellulitis and results of treatment. Laryngoscope. 1982 Jul;92(7 Pt 1):732-8.
Weiss A, Friendly D, Eglin K, et al. Bacterial periorbital and orbital cellulitis in childhood. Ophthalmology. 1983 Mar;90(3):195-203.

Causes

Periorbital and orbital cellulitis are usually caused by bacterial or fungal infections of the sinuses near the nose. Insect bites or injuries that break the skin cause about 33% of ocular cellulitis cases. Ocular cellulitis may also occur in patients who have a history of dental infections.
Periorbital cellulitis: Periorbital cellulitis can be caused by local trauma (including insect bites), contagious infections (like conjunctivitis, hordeolum or lacriminal), infections caused by bacteria in the bloodstream or infections caused by sinusitis.
Orbital cellulitis: In children (especially ages six to seven), orbital cellulitis is usually the result of a bacterial sinus infection caused by Haemophilus influenzae. Other organisms such as Staphylococcus aureus, Streptococcus pneumoniae, and beta-hemolytic streptococci may also cause orbital cellulitis. Less common causes of orbital cellulitis include an infection or recent injury to the eyelid.

Symptoms

Periorbital cellulitis: Common symptoms include swollen, painful and red eyelids, as well as runny nose and conjunctivitis (pinkeye). Conjunctivitis is an inflammation of the mucus membrane that surrounds the eyelid and covers the sclera (white part of the eyeball). Conjunctivitis can be caused by allergies or a bacterial or viral infection. Most patients do not experience fever.
Orbital cellulitis: Orbital cellulitis may progress very quickly in children, and requires immediate medical attention to avoid loss of vision. Children are especially at risk for severe infections that could result in blindness. Orbital cellulitis symptoms may include fever (usually 102 degrees Fahrenheit or higher), painful swelling of the upper and lower eyelids, red or purple eyelids, eye pain (especially with movement), decreased vision, proptosis (bulging or displacement of the eye), malaise (general feeling of discomfort), chemosis (swollen mucous membrane of the eyeball and eyelid) and ophthalmoplegia (paralysis of nerves that control eye movements).
Complications: Infections that spread beyond the eye socket may cause abscesses (collection of pus in cavities) in the brain or meninges (protective membranes that surrounds the brain), bacterial meningitis (infection and inflammation in the meninges), blood clots or vision loss. Complications can be prevented if antibiotics are started early to treat the infection.

Diagnosis

Periorbital cellulitis:
Blood culture: A blood culture is used to detect the presence of organisms that cause infection. A sample of blood is taken and analyzed for harmful bacteria or fungus. The most common offenders include, H. influenzae, streptococcus, staphylococcus or diplococcus.
Computerized tomography (CT) scan: A computerized tomography (CT) scan of the eye socket should be conducted to rule out orbital cellulitis. A CT scan may also distinguish sinusitis as the cause of the infection.
Orbital cellulitis:
Blood culture: A blood culture is commonly used to detect the presence of organisms that cause infection. A sample of blood is taken and analyzed for harmful bacteria or fungus. The most common offenders include, H. influenza, streptococcus, staphylococcus or diplococcus.
Eye exam: An ophthalmologist (eye doctor) may examine the eye to evaluate the position of the eyeball and movement of the eye. A vision test may also be performed to detect any vision loss.
Sinus x-ray: X-rays of the sinuses may show cloudiness in the sinus cavities, which is associated with orbital cellulitis.

Treatment

General: Children typically suffer from more severe infections than adults, and they usually require hospitalization until the infection is under control. Infection usually improves rapidly with antibiotic or antifungal treatment. Intravenous antibiotics or antifungals are used to stop the spread of infection and prevent damage to the optic nerve. Different antibiotics/antifungals are prescribed depending on the organism that causes the infection. Depending on the severity of the infection, treatment can last anywhere from six hours to several days. If the infection has spread to the sinus cavity close to the brain, surgery may be necessary.
Cefuroxime (Ceftin?): One of the most commonly prescribed antibiotics is cefuroxime (Ceftin?). Cefuroxime has been administered intravenously to treat infections caused by Proteus mirabilis, H. influenzae, E. coli, Klebsiella pneumoniae and Moraxella catarrhalis.
Ceftriaxone and clindamycin: Ceftiaxone and clindamycin have been used concomitantly to treat bacterial infections associated with ocular cellulitis. Treatment generally lasts from six hours to three days.
Nafcillin (Unipen?): Nafcillin (Unipen?) has been used to treat infections caused by Staphylococcus or Streptococcus.
Ticarcillin (Ticar?): Ticarcillin (Ticar?) has been used to treat bacterial infections caused by many different organisms, including H. influenzae and S. aureus.
Antifungals: Antifungals like amphotericin B (AmBisome?) are used to treat fungal infections that cause ocular cellulitis. The medication is administered intravenously. In severe cases, antifungal treatment may begin before a diagnosis is confirmed.
Nasal decongestants: Nasal decongestants like phenylephrine (Neo-Synephrine?) or oxymetazoline (Afrin?, Sinarest? or Allerest?) have been used to treat orbital cellulitis that is caused by sinusitis. Nasal decongestants may help open the sinuses and aid with drainage.
Surgery: If the infection has spread to the sinus cavity close to the brain, surgery may be necessary. An ophthalmologist or otolaryngologist will surgically drain the eye sockets and/or sinus cavities.

Integrative therapies

Good scientific evidence:
Iodine: Povidone-iodine solutions appear to have broad-spectrum activity against bacteria and have been used in the management of childhood bacterial conjunctivitis. Povidone-iodine solutions may also be used for ophthalmia neonatorum, a type of bacterial conjunctivitis with eye discharge that occurs during the first month of life, and may be as effective as other anti-bacterial solutions such as neomycin-polymyxin B-gramicidin. Medical supervision is recommended and povidone-iodine solutions are not an effective treatment for viral conjunctivitis.
Reactions can be severe and deaths have occurred with exposure to iodine. Avoid iodine-based products if allergic or hypersensitive to iodine. Do no use for more than 14 days. Avoid Lugol solution and saturated solution of potassium iodide (SSKI, PIMA) with hyperkalemia (high amounts of potassium in the blood), pulmonary edema (fluid in the lungs), bronchitis, or tuberculosis. Use cautiously when applying to the skin because it may irritate/burn tissues. Use sodium iodide cautiously with kidney failure. Avoid sodium iodide with gastrointestinal obstruction. Iodine is safe in recommended doses for pregnant or breastfeeding women. Avoid povidone-iodine for perianal preparation during delivery or postpartum antisepsis.
Unclear or conflicting scientific evidence:
Eyebright: Eyebright has been used in eye solutions for centuries to manage multiple eye conditions. Currently, there is insufficient scientific evidence to recommend for or against the use of eyebright in the treatment of conjunctivitis.
Avoid if allergic to eyebright, any of its constituents or members of the Scrophulariaceae family. Use cautiously as an eye treatment, particularly homemade preparations, due to the risk of infection if it is not sterile. Use cautiously with diabetes and drugs that are broken down by the liver. Avoid if pregnant or breastfeeding.

Prevention

The Haemophilus influenzae B (HiB) vaccine can effectively prevent nearly all Haemophilus infections, which often lead to ocular cellulitis. H. influenzae is a widespread bacteria that is present in about 75% of people. However, individuals who have healthy immune systems do not experience symptoms of the disease. Therefore, children (up to 12 months old) and individuals who have compromised immune systems typically experience the most benefit from the vaccine. The patient receives one immunization, administered intravenously, during his/her lifetime.
Proper evaluation and early treatment of sinus, dental or other infections may prevent the spread of an infection to the eyes.