Periorbital swelling

Background

Periorbital anatomy.
Anterior view of the right eye, with lacrimal duct shown medial.
  • This page describes a general approach to the complaint of periorbital swelling[1][2]
  • The critical EM distinction is preseptal (periorbital) cellulitis vs. orbital cellulitis
    • The orbital septum is the key anatomic landmark separating the two
    • Preseptal cellulitis: infection anterior to the orbital septum — common, usually manageable outpatient
    • Orbital cellulitis: infection posterior to the orbital septum — emergency with vision-threatening and life-threatening complications
  • Other important causes include allergic reactions, insect stings, angioedema, and nephrotic syndrome

Clinical Features

History

  • Onset: acute (hours — allergic, infectious, trauma) vs. gradual (days — cellulitis, systemic)
  • Unilateral vs. bilateral:
    • Unilateral: more likely infectious (cellulitis, dacryocystitis), traumatic, or insect sting
    • Bilateral: more likely systemic (allergic, nephrotic syndrome, thyroid disease, SVC syndrome)
  • Recent sinus symptoms (sinusitis is the most common cause of orbital cellulitis)
  • Recent trauma, insect bite/sting, skin break
  • Fever (infection)
  • Pain, particularly with eye movement (orbital cellulitis)
  • Vision changes, diplopia (orbital cellulitis — concerning for optic nerve compression)
  • Dental pain or recent dental procedure (odontogenic source)
  • Allergic history, medication changes

Physical Exam

  • Extent and distribution of swelling (unilateral vs. bilateral, periorbital vs. diffuse face)
  • Erythema, warmth, tenderness
  • Key findings distinguishing orbital from preseptal cellulitis:
    • Pain with extraocular movements (orbital)
    • Proptosis (orbital)
    • Decreased visual acuity (orbital)
    • Ophthalmoplegia / limited extraocular movements (orbital)
    • Afferent pupillary defect (orbital — suggests optic nerve involvement)
    • Chemosis (orbital)
  • Palpate for fluctuance (abscess)
  • Examine for dacryocystitis (medial canthal swelling, expressible purulence from punctum)

Periorbital swelling images

Red Flags

  • Pain with eye movement → orbital cellulitis
  • Decreased visual acuity → optic nerve compromise
  • Proptosis → retrobulbar process
  • Bilateral periorbital edema in child → nephrotic syndrome
  • Periorbital swelling + lip/tongue swelling + dyspnea → angioedema / anaphylaxis
  • Fever + periorbital swelling + altered mental status → cavernous sinus thrombosis

Differential Diagnosis

Periorbital swelling

Proptosis

No proptosis

Lid Complications

Other

Infectious

  • Preseptal cellulitis (most common infectious cause)
  • Orbital cellulitis (emergency — often from adjacent sinusitis)
  • Dacryocystitis (medial canthal swelling)
  • Hordeolum/chalazion (focal eyelid swelling)
  • Herpes zoster ophthalmicus (V1 distribution)

Allergic/Inflammatory

  • Allergic reaction / angioedema
  • Insect bite/sting
  • Contact dermatitis
  • Idiopathic orbital inflammation (orbital pseudotumor)

Systemic

Traumatic

  • Blunt trauma / periorbital hematoma
  • Orbital fracture with subcutaneous emphysema
  • Subperiosteal hematoma

Evaluation

Bedside

  • Visual acuity (each eye)
  • Pupillary exam (RAPD)
  • Extraocular movements
  • IOP if proptosis present

Laboratory

  • CBC with differential if infection suspected
  • Blood cultures if febrile or toxic-appearing
  • UA with urine protein, BMP, albumin if bilateral edema and nephrotic syndrome suspected
  • ESR, CRP for inflammatory markers

Imaging

  • CT orbits with contrast (with thin cuts through sinuses): gold standard for distinguishing orbital from preseptal cellulitis
    • Evaluates for orbital abscess, subperiosteal abscess, sinusitis, and cavernous sinus
  • CT should be obtained whenever orbital cellulitis is suspected
  • MRI/MRV if cavernous sinus thrombosis suspected

Management

Preseptal Cellulitis

  • Outpatient oral antibiotics in most cases: amoxicillin-clavulanate or clindamycin
  • Warm compresses
  • Close follow-up in 24-48 hours
  • IV antibiotics if: young child (<1 year), unable to take oral, toxic-appearing, failed outpatient therapy

Orbital Cellulitis

  • Admit for IV antibiotics: vancomycin + ceftriaxone (or ampicillin-sulbactam + vancomycin)
  • ENT and ophthalmology consultation
  • Surgical drainage for subperiosteal or orbital abscess if meeting criteria (large abscess, no improvement with IV antibiotics, vision compromise)
  • Monitor visual acuity serially

Allergic/Angioedema

Dacryocystitis

  • Warm compresses, oral antibiotics (amoxicillin-clavulanate)
  • Ophthalmology referral for recurrent cases (may need dacryocystorhinostomy)
  • IV antibiotics if severe/periorbital spread

Disposition

Admit

  • Orbital cellulitis
  • Preseptal cellulitis in young infants or immunocompromised
  • Cavernous sinus thrombosis
  • Angioedema with airway concern

Discharge

  • Uncomplicated preseptal cellulitis with oral antibiotics and 24-48 hour follow-up
  • Allergic periorbital swelling responding to antihistamines
  • Insect bite/sting without systemic reaction
  • Return precautions: worsening swelling, vision changes, pain with eye movement, fever, difficulty breathing

See Also

Eye Algorithms

References

  1. ↑ Tsirouki T, et al. Orbital cellulitis. Surv Ophthalmol. 2018 Jul-Aug;63(4):534-553. PMID 29248536
  2. ↑ Wong SJ, Levi J. Management of pediatric orbital cellulitis: A systematic review. Int J Pediatr Otorhinolaryngol. 2018 Jul;110:123-129. PMID 29859573
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