Cellulitis, Orbital

Cellulitis, Orbital is a topic covered in the 5-Minute Clinical Consult.

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  • Acute, severe, vision-threatening infection of orbital contents posterior to orbital septum. Preseptal (previously referred to as periorbital) cellulitis is anterior to the septum. Distinguishing location determines the appropriate workup and treatment.
  • Synonym(s): postseptal cellulitis
  • Differentiating orbital from preseptal cellulitis is the critical diagnostic step. Preseptal cellulitis can be identified by exam or, if needed, by CT scan.
  • Both preseptal and orbital cellulitis present with a red, swollen painful eye or eyelid.
  • Diplopia, proptosis, vision loss, and fever suggest orbital involvement.
  • Contrast CT is the imaging method of choice and must be done for suspicion of orbital cellulitis.
  • Treat with immediate IV antibiotics, hospital admission, and ophthalmology referral.
  • Monitor frequently for vision loss, cavernous sinus thrombosis, abscess, and meningitis.


  • No difference in frequency between genders in adults
  • More common in children; mean age of surgical cases: 10.1 years; medical pediatric cases: 6.1 years
  • Much less common than preseptal cellulitis

Orbital cellulitis has declined since Haemophilus influenzae type b (Hib) vaccine was introduced. Haemophilus is no longer the leading cause of orbital cellulitis (1,2)[B].

Etiology and Pathophysiology

  • Sinusitis is classically associated with orbital cellulitis. Local skin conditions are typically associated with preseptal cellulitis.
  • The ethmoid sinus is separated from the orbit by the lamina papyracea (“layer of paper”), a thin bony separation, and is often the source of contiguous spread of infection to the orbit.
  • The orbital septum is a connective tissue barrier that extends from the skull into the lid and separates the preseptal from the orbital space.
  • Cellulitis in the closed bony orbit causes proptosis, globe displacement, orbital apex syndrome (mass effect on the cranial nerves), optic nerve compression, and vision loss.
  • Cultures of surgical specimens in adults often grow multiple organisms. In over 1/3 of cases, no pathogen is recovered (3)[B].
  • Most common organisms (1,2)[C]:
    • Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus anginosus
  • Less common organisms:
    • Moraxella catarrhalis, H. influenzae, group A β-hemolytic Streptococcus, Pseudomonas aeruginosa, anaerobes, phycomycosis (mucormycosis), aspergillosis, Mycobacterium tuberculosis, Mycobacterium avium complex, trichinosis, Echinococcus
  • There are increasing cases of methicillin-resistant S. aureus (MRSA).

No known genetic predisposition

Risk Factors

  • Sinusitis present in 80–90% of cases (1)[C]
  • Orbital trauma, retained orbital FB, ophthalmic surgery
  • Dental, periorbital, skin, or intracranial infection; acute dacryocystitis (inflammation of the lacrimal sac) and acute dacryoadenitis (inflammation of the lacrimal gland)
  • Atopy and HSV can lead to recurrent episodes (2).
  • Immunosuppressed patients are at increased risk of adverse outcomes.

General Prevention

  • Routine Hib vaccination
  • Appropriate treatment of bacterial sinusitis
  • Proper wound care and perioperative monitoring of orbital surgery and trauma
  • Avoid trauma to the sinus and orbital regions.
  • High index of suspicion in febrile patients presenting with periocular pain, swelling, and erythema

Commonly Associated Conditions

  • Trauma and intraorbital FB
  • Preseptal cellulitis
  • Adverse outcomes of orbital apex syndrome, vision loss, ophthalmoplegia, abscess, meningitis, or cavernous sinus thrombosis

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