Periorbital cellulitis

Background

• Most often due to contiguous infection of soft tissues of face and eyelids
• Most patients are <10yr
• Rarely leads to orbital cellulitis

Periorbital vs Orbital Cellulitis

• Orbital cellulitis may mimic periorbital cellulitis early in its course
• Orbital cellulitis
  • Ocular emergency
  • Most often due to ethmoid sinusitis
  • May also be due to orbital trauma, endophthalmitis, infection from teeth / middle ear
  • Not caused by extension of periorbital cellulitis
• Periorbital cellulitis
  • Usually benign
  • Most often due to contiguous infection of soft tissues of face and eyelids

Clinical Features

• Swelling, tenderness, and erythema of eyelids and superficial tissues surrounding the orbit
• +/- fever
• Lack of:
  • Proptosis
  • Chemosis
  • Globe displacement
  • Limitation of eye movements
  • Pain with eye movement
  • Double vision
  • Vision loss (indicates orbital apex involvement)

Differential Diagnosis

Periorbital swelling

Proptosis

• Normal IOP
  • Orbital cellulitis
  • Orbital pseudotumor
  • Orbital tumor
• Increased IOP
  • Retrobulbar abscess
  • Retrobulbar emphysema
  • Retrobulbar hemorrhage
  • Ocular compartment syndrome
  • Orbital tumor

No proptosis

• Periorbital cellulitis/erysipelas
• Dacryocystitis (lacrimal duct)
• Dacryocele/Dacryocystocele
• Dacryostenosis
• Dacryoadenitis (lacrimal gland)
• Allergic reaction
• Nephrotic Syndrome (pediatrics)

Lid Complications

• Blepharitis (crusts)
• Chalazion (meibomian gland)
• Stye (hordeolum) (eyelash folicle)

Other

• Subperiosteal abscess
• Orbital abscess
• Cavernous sinus thrombosis
• Conjunctivitis
• Contact dermatitis
• Herpes zoster
• Herpes simplex
• Sarcoidosis
• Granulomatosis with polyangiitis

Evaluation

• CT Orbit with IV contrast if:
  • Concern for orbital cellulitis
  • Unable to accurately assess vision (e.g. age <1yr)

Management

Antibiotics

Outpatient

Treatment recommended for 5-7 days. If signs of cellulitis persist at the end of this period, treatment should be continued until the eyelid erythema and swelling have resolved or nearly resolved.

• TMP/SMX 1-2 double-strength tablets BID OR

- In children: TMP/SMX 8 to 12 mg/kg QD of the TMP component divided every 12 hours

• Clindamycin 300mg Q8H - In children: Clindamycin 30 to 40 mg/kg per day in three to four equally divided doses, maximum 1.8 grams per day

PLUS one of the following agents:

• Amoxicillin 875 mg BID OR

- In children: Amoxicillin 45-90 mg/kg per day divided every 12 hours

• Cefpodoxime 400mg BID OR

- In children: Cefpodoxime 10 mg/kg per day divided every 12 hours, max 200 mg

• Cefdinir 300 mg BID - In children: Cefdinir 14 mg/kg per day, divided every 12 hours, max daily 600 mg

Inpatient

• Vancomycin 15-20mg/kg IV BID + (one of the following)
  • Ampicillin/Sulbactam 3 g IV q6hr OR
  • Ticarcillin/Clavulanate 3.1 g IV q4h OR
  • Piperacillin/Tazobactam 4.5 g IV q6h OR
  • Ceftriaxone 2 g IV q12hr OR
  • Cefotaxime 2 g IV q4h

Pediatric:

• Vancomycin 15mg/kg IV q6hrs + (one of the following)
  • Ampicillin/Sulbactam 50mg/kg IV q6hrs (max 3g/dose) OR
  • Piperacillin/Tazobactam 100mg/kg IV q8hrs (max 4.5g) OR
  • Ceftriaxone 50mg/kg IV q12hrs (max 2g/dose) OR
  • Cefotaxime 50mg/kg IV q6hrs (max 2g/dose)

Disposition

• If well-appearing and afebrile consider discharge

See Also

• Periorbital Swelling
• Periorbital vs Orbital Cellulitis
• Orbital Cellulitis