Periorbital Cellulitis Treatment And Prevention

What is periorbital cellulitis?

Periorbital cellulitis, or pre-septal cellulitis, refers to an infection of the skin, soft tissue and bony structure surrounding the eye (anterior to the orbital septum). This condition can sometimes be confused with orbital cellulitis, an infection that affects the eye and its tissues within the bony cavity of the face (posterior to the orbital septum. It is important to note that periorbital cellulitis is usually more common yet less serious compared to orbital cellulitis.¹

This article will give an overview of periorbital cellulitis including its causes, risk factors, clinical symptoms and management.

Epidemiology

Periorbital cellulitis predominantly affects children, but adults can get it too. Approximately 80% of patients are younger than 10 years. It is also twice as common among men when compared to women. Therefore early diagnosis and management is vital.²

Causes and risk factors

Can be triggered by several factors; however, it is primarily caused by trauma or sinusitis.

Bacteria can enter the eye and its surrounding cavity through various means. The two primary routes of infection are as follows:

• Injury: direct injury to the eye can result in bacterial infection such as an insect bite or scratch³
• Spread from adjacent regions: Frequently, infections originate in the sinuses, which are air-filled pockets near the nasal passage

Common causative pathogens:⁴

• Streptococcus pyogenes and Staphylococcus aureus(hyperlink) are the culprits when infection results from local trauma.
• Streptococcus pneumoniae is the most common pathogen linked with sinus infections.
• Haemophilus influenzae type b, which was formerly abundant, is now uncommon due to widespread immunization.
• Fungi are rare microorganisms that can cause orbital cellulitis in diabetics or immunocompromised individuals.

There are several risk factors to consider that can lead to the development of periorbital cellulitis.⁴

• Recent trauma to the eye region
• Recent eye or ENT surgery
• Immunocompromised individuals
• Recent upper respiratory tract infection
• Rubbing or irritation of the eyes
• History of sinusitis or asthma
• Young children
• Impetigo (skin infection)

What are the symptoms?

Some of the common symptoms of periorbital cellulitis include:⁵

• Unilateral swelling of the eyelid
• Pain or discomfort of the eye– acute onset
• Tenderness
• Erythema
• Red eyes
• Fever
• Tiredness
• Visual changes
• Irritability of children

How do you diagnose periorbital cellulitis?

It is critical to distinguish between periorbital cellulitis and orbital cellulitis since therapy and management vary depending on the diagnosis. In many situations, the differentiation between the two conditions is ambiguous.

Periorbital cellulitis is mostly diagnosed based on clinical signs and radiologic findings. Chandler’s classification, ranging from stages I-V, can be used to classify the severity. Here are some of the key investigations that can be used to aid in the diagnosis:⁶

• Cranial nerve examination
• Eye exam
• Nasal examination – to assess any rhino sinusitis.
• Routine blood test
• Cultures from the eyelid, any conjunctival discharge or nasal secretions
• Blood cultures – positive in less than 10% of patients, so not always necessary unless sepsis is suspected⁶
• Swabs
• CT or MRI scan – can help map out the extent of orbital involvement

Differentials:

Many differential diagnoses must be excluded before reaching periorbital cellulitis. These include:⁷

• Orbital cellulitis – involves bulging of the eyeball, painful and restricted eye movement, colour vision and visual acuity and a pupillary defect, in severe cases whereas these signs are not present with periorbital cellulitis.
• Cavernous sinus thrombosis - blood clot in the sinus usually due to the spread of infection.
• Angioedema
• Retinoblastoma
• Hermes simplex and herpes zoster
• Allergic dermatitis
• Blepharitis
• Conjunctivitis
• Thyroid eye disease
• Dacryocystitis
• Chalazion

How is it managed?

If the patient presents with mild symptoms, without a fever, outpatient management may be appropriate, involving oral antibiotics and daily check-ups to track the disease progression. However, in younger patients or in cases where there's no improvement with oral antibiotics within 48 hours or if there are concerns about the infection spreading into the orbit, hospital admission may be required. An urgent referral is warranted if there is any uncertainty about the diagnosis.⁸

Moreover, periorbital cellulitis is managed by the collaboration of a multidisciplinary team involving an ophthalmologist, general practitioner, ENT and paediatrician.

Non-pharmacological treatment

• A cold compress can be used to ease discomfort and swelling of the eye
• Surgical drainage may be an option for abscesses of the eyelid or complicated periorbital cellulitis in groups 3 and above of the Chandler classification. This can be done endoscopically through the nasal cavity or via an open approach¹

Pharmacological treatment

The main treatment option for periorbital cellulitis involves taking a course of antibiotics for at least 5-7 days. Other considerations include a topical decongestant, IV hydration and analgesia.⁸

Oral antibiotic

• For Gram-positive bacteria, particularly Staphylococcus in instances of eyelid trauma, the following are recommended: Dicloxacillin, Flucloxacillin, and first-generation cephalosporins such as cephalexin and cefazolin
• Effective against both Gram-positive and Gram-negative bacteria are: Ampicillin, Amoxicillin/clavulanate, Fluoroquinolones (levofloxacin), Azithromycin (which also provides coverage against certain anaerobic bacteria), and Clindamycin

Intravenous antibiotic

Ampicillin, sulbactam and third-generation antibiotics such as ceftriaxone can be used against both gram-positive and negative bacteria.⁸

MRSA Resistance

If cultures show MRSA resistance, the choice of antibiotic should be reconsidered. Vancomycin or Linezolid can be tried for hospital-associated MRSA. Whereas, rifampin, fluoroquinolones and clindamycin can be used for community-acquired MRSA.⁸

An alternative antibiotic such as clindamycin can be used for individuals with penicillin allergy.

Prognosis and complications

The overall mortality is approximately 2.5%.^⁹ When periorbital cellulitis is diagnosed and managed promptly, the prognosis is excellent. Nevertheless, delayed treatment amongst other morbidities may lead to potential complications such as:⁵

• Progression to orbital cellulitis
• Meningitis
• Vision loss
• Brain abscess
• Cavernous sinus thrombosis ( hyperlink)

Prevention

Awareness of periorbital cellulitis among patients, parents and healthcare professionals is one of the key ways to recognise the early signs and possible red flag symptoms to then guide successful management. The incidence of this condition can be reduced by practising good hand hygiene and following social distancing when others are ill. An annual flu vaccination may also help in decreasing the likelihood of any infections.⁹

FAQ’s

Is periorbital cellulitis contagious?

No, it cannot be passed from one person to another.

What are the side effects of the treatment?

Side effects vary depending on the type of drug. General ones to consider include allergic reactions, gastrointestinal symptoms and antibiotic resistance.

When should I go to the A and E?

Visual impairment, bulging of the eyes, painful or limited eye movement, headache, fever.