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Definitions

• Orbital Septum
  • Membranous structure that extends from orbit to the tarsal plate and is the anterior boundary of the orbital compartment
• Preseptal Cellulitis
  • Infection of the soft tissues ANTERIOR to the orbital septum
• Orbital Cellulitis
  • Infections of the soft tissues POSTERIOR to the orbital septum

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Numbers

• Preseptal cellulitis is much more common than orbital (>90%)
• Both conditions are more common in children than adults

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Pathogenesis

• Preseptal
  • Usually due to superficial dermatologic infections (though the data has wide variability in reported causes)
• Orbital
  • Bacterial rhinosinusitis
    • Due to perforations in the lamina papyracea
  • Other causes:
    • Ophthalmologic surgery
    • Dacrocystitis
    • Orbital trauma
    • Dental infections
      

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Microbiology

• Preseptal
  • Staphylococcus aureus (skin causes)
    • Increasing incidence of MRSA
  • Streptococcus pneumoniae (sinus/nasopharynx causes)
• Orbital
  • Same as preseptal, but include:
    • Fungal (mucormycosis and Aspergillus spp.)

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Signs and Symptoms

• Both present with unilateral eyepain, erythema, and edema, but:
• Preseptal
  • No pain with eye movement
  • Sclera is white

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  • Orbital
    • Painful eye movement
    • Vision changes (acuity, diplopia)
    • Proptosis
    • Sclera injection and chemosis
    • Decreased pupillary response

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Complications

• Complications of preseptal cellulitis are rare, but orbital cellulitis can lead to:
  • Vision loss (3-11%)
  • Subperiosteal abscess
  • Orbital abscess
  • Cavernous sinus thrombosis

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Diagnostic Studies

• CBC with differential may be helpful in risk stratification or atypical presentation
• Preseptal
  • None! –> Clinical diagnosis
• Orbital
  • Indications for CT scan
    • Inability to assess vision or deteriorating vision
    • Double vision
    • Inability to examine due to age
    • Proptosis
    • Restricted, limited, and/or painfuleye movement
    • Edema extending beyond eyelid margin
    • Lack of improvement in 24 hours on antibiotics
    • Cyclical fevers
    • Signs of CNS involvement
    • ANC > 10,000 cell/microL

• Blood cultures are not routinely recommended but should be entertained in ill appearing children prior to antibiotic administration
  

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Treatment

• Preseptal
  • Outpatient
    • > 1 year old and no signs of systemic toxicity
    • Treatment duration typically 5-7days, but treatment should continue until eyelid erythema and swelling have resolved
  • Inpatient
    • < 1 year old, children who can’t cooperate with exam, toxic appearance, or outpatient treatment failing to improve in 24-48 hours
    • Follow orbital cellulitis treatment
      

• Orbital
  • Medical
    • Staphylococcal coverage
      • Vancomycin
    • Streptococcal coverage
      • Ceftriaxone
      • Cefotaxime
    • Anaerobic coverage
      • Metronidazole
    • Improvement should occur within24-48 hours
    • Transition to oral therapy when:
      • Afebrile and periorbital signs are resolving
      • Typically 3-5 days
      • Follow culture data (if obtained) or follow outpatient preseptal cellulitis regimen
    • Treat for a total of 2-3 weeks
  • Surgical indications
    • Radiographically identified abscess
      • Typically > 10mm, though small abscesses respond to antibiotics well
    • Intracranial extension
    • Failure to respond to antibiotic treatment
    • Threat to vision

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References

1. Hauser A, Fogarasi S. Periorbital and orbital cellulitis. Pediatrics in review. 2010; 31(6):242-9. [pubmed]
2. Botting AM, McIntosh D, Mahadevan M. Paediatric pre- and post-septal peri-orbital infections are different diseases. A retrospective review of 262 cases. International journal of pediatric otorhinolaryngology. 2008; 72(3):377-83. [pubmed]
3. Horton JC. Disorders of the Eye. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison’s Principles of Internal Medicine, 20e New York, NY: McGraw-Hill; http://accessmedicine.mhmedical.com/content.aspx?bookid=2129&sectionid=192011900
4. Chaudhry IA, Shamsi FA, Elzaridi E, Al-Rashed W, Al-Amri A, Arat YO. Inpatient preseptal cellulitis: experience from a tertiary eye care centre. The British journal of ophthalmology. 2008; 92(10):1337-41. [pubmed]
5. Moran GJ, Krishnadasan A, Gorwitz RJ, et al. Methicillin-resistant S. aureus infections among patients in the emergency department. The New England journal of medicine. 2006; 355(7):666-74. [pubmed]
6. Brook I, Frazier EH. Microbiology of subperiosteal orbital abscess and associated maxillary sinusitis. The Laryngoscope. 1996; 106(8):1010-3. [pubmed]
7. Erickson BP, Lee WW. Orbital Cellulitis and Subperiosteal Abscess: A 5-year Outcomes Analysis. Orbit (Amsterdam, Netherlands). 2015; 34(3):115-20. [pubmed]
8. Howe L, Jones NS. Guidelines for the management of periorbital cellulitis/abscess. Clinical otolaryngology and allied sciences. 2004; 29(6):725-8. [pubmed]
9. Rudloe TF, Harper MB, Prabhu SP, Rahbar R, Vanderveen D, Kimia AA. Acute periorbital infections: who needs emergent imaging? Pediatrics. 2010; 125(4):e719-26. [pubmed]
10. Tanna N, Preciado DA, Clary MS, Choi SS. Surgical treatment of subperiosteal orbital abscess. Archives of otolaryngology–head & neck surgery. 2008; 134(7):764-7. [pubmed]
11. Greenberg MF, Pollard ZF. Medical treatment of pediatric subperiosteal orbital abscess secondary to sinusitis. Journal of AAPOS : the official publication of the American Association for Pediatric Ophthalmology and Strabismus. 1998; 2(6):351-5. [pubmed]