Preseptal cellulitis Authors Christopher Gappy, MD Steven M Archer, MD Michael Barza, MD Section Editors Stephen B Calderwood, MD Jonathan Trobe, MD Morven S Edwards, MD Deputy Editor Allyson Bloom, MD All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Sep 2015. | This topic last updated: Jun 24, 2015. INTRODUCTION — Preseptal cellulitis (sometimes called periorbital cellulitis) is an infection of the anterior portion of the eyelid, not involving the orbit or other ocular structures. In contrast, orbital cellulitis is an infection involving the contents of the orbit (fat and ocular muscles) but not the globe. Although preseptal and orbital cellulitis may be confused with one another because both can cause ocular pain and eyelid swelling and erythema, they have very different clinical implications. Preseptal cellulitis is generally a mild condition that rarely leads to serious complications, whereas orbital cellulitis may cause loss of vision and even loss of life. Orbital cellulitis can usually be distinguished from preseptal cellulitis by its clinical features (ophthalmoplegia, pain with eye movements, and proptosis) and by imaging studies. In cases in which the distinction is not clear, clinicians should treat patients as though they have orbital cellulitis. Both conditions are more common in children than in adults, and preseptal cellulitis is much more common than orbital cellulitis. The pathogenesis, microbiology, clinical manifestations, diagnosis, and treatment of preseptal cellulitis will be reviewed here. Orbital cellulitis and its complications, such as subperiosteal abscess and orbital abscess, are discussed separately. Orbital infections caused by fungi, mainly the Mucorales (which cause mucormycosis) andAspergillus spp and, much more rarely, Mycobacterium tuberculosis, are also presented elsewhere. (See "Orbital cellulitis" and "Mucormycosis (zygomycosis)" and"Epidemiology and clinical manifestations of invasive aspergillosis" and "Tuberculosis and the eye" .) TERMINOLOGY — Preseptal cellulitis and orbital cellulitis involve different anatomic sites, with preseptal cellulitis referring to infections of the soft tissues anterior to the orbital septum and orbital cellulitis referring to infections posterior to it (figure 1 ). Neither infection involves the globe. (See 'Anatomy' below.) There is some debate regarding the appropriate terminology for these infections. Some clinicians use the term "periorbital cellulitis" rather than "preseptal cellulitis" or use the terms interchangeably. We prefer the term "preseptal cellulitis" to make a clear distinction between this infection and the more serious infection, "orbital cellulitis." Orbital cellulitis is sometimes referred to as "postseptal cellulitis"; we favor the term "orbital cellulitis," and will use it throughout this topic. ANATOMY — Basic familiarity with the anatomy of the eye is fundamental to understanding the pathogenesis, clinical manifestations, and complications of preseptal and orbital cellulitis. The orbit is a cone-shaped structure, lying horizontally, with its apex in the skull. It is surrounded by paranasal sinuses, namely, the frontal (lying superior), ethmoid (medial) and maxillary (inferior) sinuses (figure 2 ). The orbit is lined by periosteum. The ethmoid sinuses are separated from the orbit by a paper-thin layer called the lamina papyracea, which contains many perforations for nerves and blood vessels as well as some natural fenestrations termed Zuckerkandl’s dehiscences. Th e most common route of infection of the orbit is by extension from the ethmoid sinuses, presumably through these perforations. The orbital septum is a membranous sheet that extends from the periosteum of the orbit to the tarsal plate and forms the anterior boundary of the orbital compartment (figure 1 ). As noted above, preseptal cellulitis involves the soft tissues anterior to the orbital septum. The superior and inferior ophthalmic veins drain blood directly into the cavernous sinus (figure 3 ). Because of this communication and because the inferior orbital veins are valveless, infection can pass readily from the orbit to intracranial structures [ 1 ]. EPIDEMIOLOGY — Preseptal cellulitis is much more common than orbital cellulitis. In two pediatric case series, 94 percent and 87 percent of cases, respectively, were diagnosed as preseptal cellulitis [ 2,3 ]; the remainder of cases were diagnosed as orbital cellulitis. Both infections are much more common in children than in adults; accordingly, most of the data regarding these infections comes from studies in children.
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Preseptal cellulitis Authors
Christopher Gappy, MD Steven M Archer, MD Michael Barza, MD Section Editors
Stephen B Calderwood, MD Jonathan Trobe, MD Morven S Edwards, MD Deputy Editor
Allyson Bloom, MD All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Sep 2015. | This topic last updated: Jun 24, 2015.
INTRODUCTION — Preseptal cellulitis (sometimes called periorbital cellulitis) is an infection of the anterior portion of the
eyelid, not involving the orbit or other ocular structures. In contrast, orbital cellulitis is an infection involving the contents of
the orbit (fat and ocular muscles) but not the globe. Although preseptal and orbital cellulitis may be confused with one
another because both can cause ocular pain and eyelid swelling and erythema, they have very different clinical
implications. Preseptal cellulitis is generally a mild condition that rarely leads to serious complications, whereas orbital
cellulitis may cause loss of vision and even loss of life. Orbital cellulitis can usually be distinguished from preseptal
cellulitis by its clinical features (ophthalmoplegia, pain with eye movements, and proptosis) and by imaging studies. In
cases in which the distinction is not clear, clinicians should treat patients as though they have orbital cellulitis. Both
conditions are more common in children than in adults, and preseptal cellulitis is much more common than orbital
cellulitis.
The pathogenesis, microbiology, clinical manifestations, diagnosis, and treatment of preseptal cellulitis will be reviewed
here. Orbital cellulitis and its complications, such as subperiosteal abscess and orbital abscess, are discussed separately.
Orbital infections caused by fungi, mainly the Mucorales (which cause mucormycosis) andAspergillus spp and, much
more rarely, Mycobacterium tuberculosis, are also presented elsewhere. (See "Orbital cellulitis" and "Mucormycosis
(zygomycosis)" and"Epidemiology and clinical manifestations of invasive aspergillosis" and "Tuberculosis and the eye".)
TERMINOLOGY — Preseptal cellulitis and orbital cellulitis involve different anatomic sites, with preseptal cellulitis
referring to infections of the soft tissues anterior to the orbital septum and orbital cellulitis referring to infections posterior
to it (figure 1). Neither infection involves the globe. (See 'Anatomy' below.)
There is some debate regarding the appropriate terminology for these infections. Some clinicians use the term "periorbital
cellulitis" rather than "preseptal cellulitis" or use the terms interchangeably. We prefer the term "preseptal cellulitis" to
make a clear distinction between this infection and the more serious infection, "orbital cellulitis." Orbital cellulitis is
sometimes referred to as "postseptal cellulitis"; we favor the term "orbital cellulitis," and will use it throughout this topic.
ANATOMY — Basic familiarity with the anatomy of the eye is fundamental to understanding the pathogenesis, clinical
manifestations, and complications of preseptal and orbital cellulitis. The orbit is a cone-shaped structure, lying
horizontally, with its apex in the skull. It is surrounded by paranasal sinuses, namely, the frontal (lying superior), ethmoid
(medial) and maxillary (inferior) sinuses (figure 2). The orbit is lined by periosteum. The ethmoid sinuses are separated
from the orbit by a paper-thin layer called the lamina papyracea, which contains many perforations for nerves and blood
vessels as well as some natural fenestrations termed Zuckerkandl’s dehiscences. The most common route of infection of
the orbit is by extension from the ethmoid sinuses, presumably through these perforations.
The orbital septum is a membranous sheet that extends from the periosteum of the orbit to the tarsal plate and forms the
anterior boundary of the orbital compartment (figure 1). As noted above, preseptal cellulitis involves the soft tissues
anterior to the orbital septum. The superior and inferior ophthalmic veins drain blood directly into the cavernous sinus
(figure 3). Because of this communication and because the inferior orbital veins are valveless, infection can pass readily
from the orbit to intracranial structures [1].
EPIDEMIOLOGY — Preseptal cellulitis is much more common than orbital cellulitis. In two pediatric case series, 94
percent and 87 percent of cases, respectively, were diagnosed as preseptal cellulitis [2,3]; the remainder of cases were
diagnosed as orbital cellulitis. Both infections are much more common in children than in adults; accordingly, most of the
data regarding these infections comes from studies in children.
patients as environmental allergies, and in one patient each as recurrent sinusitis, herpes simplex infection, contact
dermatitis to cosmetics, and Munchausen’s syndrome [29]. An anatomic abnormality of the sinuses may also predispose
to recurrent preseptal cellulitis [30].
SUMMARY AND RECOMMENDATIONS — Preseptal cellulitis and orbital cellulitis involve different anatomic sites, with
preseptal cellulitis referring to infections of the soft tissues anterior to the orbital septum and orbital cellulitis referring to
infections posterior to it (figure 1). Orbital cellulitis involves the muscles and fat located within the orbit. Although preseptal
and orbital cellulitis may be confused with one another because both can cause ocular pain and eyelid swelling and
erythema, they have very different clinical implications. Preseptal cellulitis is generally a mild condition that rarely leads to
serious complications, whereas orbital cellulitis may cause loss of vision and even loss of life. Orbital cellulitis can usually
be distinguished from preseptal cellulitis by its clinical features (ophthalmoplegia, pain with eye movements, and
proptosis) and by imaging studies; in cases in which the distinction is not clear, clinicians should treat patients as though
they have orbital cellulitis. Both conditions are more common in children than in adults. (See 'Introduction' above
and 'Terminology' above.)
●Preseptal cellulitis arises most commonly from sinusitis or a contiguous infection of the soft tissues of the face and
eyelids secondary to local trauma, insect or animal bites, or foreign bodies. (See 'Pathogenesis' above.)
●The most common causes of preseptal cellulitis are Streptococcus pneumoniae and other
streptococci, Staphylococcus aureus (including community-acquired methicillin-resistant S. aureus [CA-MRSA]), and
anaerobes (table 1). (See 'Microbiology' above.)
●The diagnosis of preseptal cellulitis is based upon the history (eg, insect bite, local face and/or eyelid trauma) and
physical examination. However, in cases in which there is doubt, computed tomography (CT) scanning of the orbits
and sinuses can usually distinguish preseptal cellulitis from orbital cellulitis. (See 'Diagnosis'above.)
●During the initial evaluation, it is critical to distinguish preseptal cellulitis from the more serious orbital cellulitis
(table 2 and table 3). Although both preseptal cellulitis and orbital cellulitis typically cause eyelid swelling and
erythema, the presence of ophthalmoplegia, pain with eye movements, chemosis, and/or proptosis occur only with
orbital cellulitis. (See 'Clinical manifestations' above.)
●Adults and children older than one year of age with mild preseptal cellulitis can be managed on an outpatient
basis, provided that the patient has no signs of systemic toxicity and close follow-up is ensured. In these cases, we
recommend treatment with oral antibiotics with activity against S. aureus (including MRSA) and streptococci, such
as clindamycin monotherapy or combination therapy with trimethoprim-sulfamethoxazole plus one of the following
agents: amoxicillin, amoxicillin-clavulanic acid, cefpodoxime, or cefdinir (Grade 2B). If the patient has not been
immunized against Haemophilus influenzae, one of the combination regimens should be used. (See 'Antibiotic
regimens' above.)
●We generally recommend a treatment duration of 7 to 10 days, but if signs of cellulitis persist at the end of this
period, treatment should be continued until the erythema and swelling have resolved or nearly resolved.
(See 'Duration' above.)
●Patients younger than one year of age and those who are severely ill should be admitted to the hospital and
managed according to the recommendations for orbital cellulitis. Patients with subtle clinical and/or radiographic
findings suggesting that the orbit is involved, as well as young children who are not able to cooperate for a thorough
examination, should also be treated as though they have orbital cellulitis given the serious complications of this
entity. (See "Orbital cellulitis", section on 'Treatment'.)
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REFERENCES
1. Zhang J, Stringer MD. Ophthalmic and facial veins are not valveless. Clin Experiment Ophthalmol 2010; 38:502. 2. Ambati BK, Ambati J, Azar N, et al. Periorbital and orbital cellulitis before and after the advent of Haemophilus
influenzae type B vaccination. Ophthalmology 2000; 107:1450. 3. Botting AM, McIntosh D, Mahadevan M. Paediatric pre- and post-septal peri-orbital infections are different
diseases. A retrospective review of 262 cases. Int J Pediatr Otorhinolaryngol 2008; 72:377. 4. Mills RP, Kartush JM. Orbital wall thickness and the spread of infection from the paranasal sinuses. Clin
Otolaryngol Allied Sci 1985; 10:209. 5. Jackson K, Baker SR. Periorbital cellulitis. Head Neck Surg 1987; 9:227. 6. Ganesh A, Venugopalan P. Preseptal orbital cellulitis following oral trauma. J Pediatr Ophthalmol Strabismus
7. Smith TF, O'Day D, Wright PF. Clinical implications of preseptal (periorbital) cellulitis in childhood. Pediatrics 1978; 62:1006.
8. Hutcheson KA, Magbalon M. Periocular abscess and cellulitis from Pasteurella multocida in a healthy child. Am J Ophthalmol 1999; 128:514.
9. Chaudhry IA, Shamsi FA, Elzaridi E, et al. Inpatient preseptal cellulitis: experience from a tertiary eye care centre. Br J Ophthalmol 2008; 92:1337.
10. Charalampidou S, Connell P, Fennell J, et al. Preseptal cellulitis caused by community acquired methicillin resistant Staphylococcus aureus (CAMRSA). Br J Ophthalmol 2007; 91:1723.
11. Blomquist PH. Methicillin-resistant Staphylococcus aureus infections of the eye and orbit (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc 2006; 104:322.
12. Moran GJ, Krishnadasan A, Gorwitz RJ, et al. Methicillin-resistant S. aureus infections among patients in the emergency department. N Engl J Med 2006; 355:666.
13. Miller J. Acinetobacter as a causative agent in preseptal cellulitis. Optometry 2005; 76:176. 14. Mathews D, Mathews JP, Kwartz J, Inkster C. Preseptal cellulitis caused by Acinetobacter lwoffi. Indian J
Ophthalmol 2005; 53:213. 15. Brannan PA, Kersten RC, Hudak DT, et al. Primary Nocardia brasiliensis of the eyelid. Am J Ophthalmol 2004;
138:498. 16. Caça I, Cakmak SS, Unlü K, et al. Cutaneous anthrax on eyelids. Jpn J Ophthalmol 2004; 48:268. 17. Milstone AM, Ruff AJ, Yeamans C, Higman MA. Pseudomonas aeruginosa pre-septal cellulitis and bacteremia in
a pediatric oncology patient. Pediatr Blood Cancer 2005; 45:353; discussion 354. 18. Raja NS, Singh NN. Bilateral orbital cellulitis due to Neisseria gonorrhoeae and Staphylococcus aureus: a
previously unreported case. J Med Microbiol 2005; 54:609. 19. Sears JM, Gabriel HM, Veith J. Preseptal cellulitis secondary to Proteus species: a case report and review. J Am
Optom Assoc 1999; 70:661. 20. Raina UK, Jain S, Monga S, et al. Tubercular preseptal cellulitis in children: a presenting feature of underlying
21:312. 22. Seltz LB, Smith J, Durairaj VD, et al. Microbiology and antibiotic management of orbital cellulitis. Pediatrics 2011;
127:e566. 23. Nageswaran S, Woods CR, Benjamin DK Jr, et al. Orbital cellulitis in children. Pediatr Infect Dis J 2006; 25:695. 24. Durand, ML. Periocular infections. In: Principles and Practice of Infectious Diseases, 7th ed, Mandell, GL,
Bennett, et al. (Eds), Churchill Livingstone Elsevier, Philadelphia 2010. p.1569. 25. Sobol SE, Marchand J, Tewfik TL, et al. Orbital complications of sinusitis in children. J Otolaryngol 2002; 31:131. 26. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the infectious diseases society of america for
the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 2011; 52:e18. 27. Howe L, Jones NS. Guidelines for the management of periorbital cellulitis/abscess. Clin Otolaryngol Allied Sci
2004; 29:725. 28. Uzcátegui N, Warman R, Smith A, Howard CW. Clinical practice guidelines for the management of orbital
cellulitis. J Pediatr Ophthalmol Strabismus 1998; 35:73. 29. Sorin A, April MM, Ward RF. Recurrent periorbital cellulitis: an unusual clinical entity. Otolaryngol Head Neck
Surg 2006; 134:153. 30. Karkos PD, Karagama Y, Karkanevatos A, Srinivasan V. Recurrent periorbital cellulitis in a child. A random event
or an underlying anatomical abnormality? Int J Pediatr Otorhinolaryngol 2004; 68:1529.
Diagram showing the proximity of the periosteum in relation to the orbital septum. Orbital cellulitis arises
posterior to the orbital septum
Medial wall of the left orbit (lateral wall removed)
Note the proximity of the frontal, ethmoidal, and maxillary sinuses to the orbital space. The lamina papyracea is
the thin bone wall on the surface of the ethmoid air cells.Graphic 71411 Version 5.0
Venous drainage of the orbit
The diagram demonstrates the communication between ethmoidal sinuses, the orbit, and the cavernous
sinus.
Microbiology of preseptal and orbital cellulitis*
Preseptal cellulitis Orbital cellulitis
Chaudhry,
et al[1]
Botting, et
al[2]
McKinley,
et al[3] Seltz, et al[4]
Nageswaran, et
al[5]
Botting,
et al[2] Goytia, et al[6]
Number of patients 104 227 38 94 41 35 85
Number of patients with
a positive culture
(except¶)
36 53¶ 24 29 20 11¶ 29¶
Staphylococcus aureus Δ 32 11 8 3 7 14
MSSA NR NR 3 7 NR NR 7
MRSA NR NR 8 1 NR NR 7
Alpha-hemolytic
streptococci (includingS.
pneumoniae) or non-
hemolytic streptococci
Δ 4 7 15
Beta-hemolytic
streptococci (includingS.
pyogenes)
Δ 7 13 6 5 3 10
Streptococcus
anginosus (formerly S.
milleri)
2 14 2
Rothia mucilaginosa 1
Haemophilus influenzae 8 5 3 3 3 5
Haemophilus
parainfluenzae
1
Klebsiella pneumoniae 3 1
Moraxella catarrhalis 1
Arcanobacterium spp 1 1
Eikenella corrodens 1 2
Anaerobes 2 2 8 4
Skin flora/contaminant 5 11◊ 12◊
Possible pathogen§ 10
Sites of culture Blood,
wound,
abscess
NR Blood,
orbital
abscess,
eye, sinus,
epidural
abscess,
nose
Blood,
sinus/orbit,
subdural
space
Orbital abscess,
subperiostial
abscess, sinus
NR Blood, endoscopic
sinus,
subperiosteal,
intraorbital
MSSA: methicillin-susceptible Staphylococcus aureus; MRSA: methicillin-resistant Staphylococcus aureus; NR: not
reported.* Results are reported as the number of cultures that grew a given organism. Some cultures grew >1
organism and some patients had >1 positive culture.¶ Results are reported as number of positive cultures (rather than
number of patients with a positive culture); some patients may have had >1 positive culture.Δ Staphylococcus spp
and Streptococcus spp were recovered from 26 (72 percent) of cultures, but the authors did not report the number of
positive cultures for individual species.◊ In McKinley, et al[3], coagulase-negative Staphylococcus spp was reported as
a recovered organism, but in Seltz, et al[4], this organism was classified as a contaminant. We have classified it as a
contaminant for both studies.§ The authors of this study classifed some (but not all) sinus/orbit cultures as possible
pathogens rather than true pathogens.
Orbital cellulitis
This young girl has erythema and edema in the preseptal area, which could be caused by either orbital
or preseptal infection.
Clinical features of preseptal and orbital cellulitis
Clinical feature Preseptal cellulitis Orbital cellulitis
Eyelid swelling with or without erythema Yes Yes
Eye pain/tenderness May be present Yes; may cause deep eye pain
Pain with eye movements No Yes
Proptosis No Usually, but may be subtle
Ophthalmoplegia +/- diplopia No Yes
Vision impairment No May be present*
Chemosis Rarely present May be present
Fever May be present Usually present
Clinical manifestations of preseptal and orbital cellulitis studies on admission
Study: Study design, patient population
Nageswaran, et
al[1]
:Retrospective,
children
Botting, et
al[2]
:Retrospective,
children
Chaudhry, et
al[3]
:Retrospective¶,
children and adults
Sobol, et al[4]
:Retrospective,
children
Seltz, et
al[5]
:Retrospective,
children
Type of cellulitis Type of cellulitis Type of cellulitis Type of cellulitis Type of cellulitis
Preseptal Orbital
(n = 41)
Preseptal
(n =
227)
Orbital
(n =
35)
Preseptal (n = 104) Orbital Preseptal
(n =
101)
Orbital
(n =
26)Δ
Preseptal Orbital
(n = 94)
Age (yrs)◊ 7.5
(range 0-
16)
3.9 7.5 19 (range 0-75) 3.8
(range 0-
16)
6.4
(range
0-13)
6 (range
0-18)
History of
trauma*
Excluded 89 (39) 4 (11) 28 Excluded
Eye pain and/or
tenderness
64 (62)
Eyelid swelling
+/– erythema
104 (100)
Proptosis 25 (61) 2 (0.9) 33
(94)
1 (1) 20
(77)
36 (38)
Ophthalmoplegia 19 (46) 1 (0.4) 4 (11) 1 (1) 20
(77)
45 (48)
Diplopia 2 (0.9) 19
(54)
Vision impaired 0 1 (3) 3 (3) 3 (11) 11 (12)
No
ophthalmologic
signs (proptosis,
ophthalmoplegia,
visual loss)
11 (27)
Chemosis 10 (11)
Fever 27 (66) 106 (47) 33
(94)
Children 52 percent;
adults 10 percent
59 (59) 18
(69)
63 (67)
White blood cell 19 (46)
count >15,000
Sinusitis§ 21 (9) 32
(91)
Ethmoid
sinusitis
40
(98)
30
(86)
22
(86)
87
(93)
Maxillary
sinusitis
29
(71)
21
(60)
22
(86)
84
(89)
Subperiosteal
abscess
24 (59) 12
(34)
Δ 44 (47)
Orbital abscess 10 (24) 2 (6) 0 8 (8)
>Surgical
procedure
29 (71) 11 (5) 8 (23) 52 (50)¶ 0 6 (23)
Δ
Results are reported as number of patients with a given finding (percent). * Eg, insect bites, scratches. ¶ This study
involved patients referred to a tertiary care hospital in Saudi Arabia. 38.5 percent of patients were >16 years of age.
Many had acute dacryocystitis, trauma, or recent surgery, which is probably why such a large proportion of patients
underwent surgical procedures. Δ In this study, 12 cases of children with subperiosteal abscess were evaluated
separately; these cases are not shown in the table, but the findings were similar to those with simple orbital cellulitis. Of
patients with orbital cellulitis or subperiosteal abscess, 12 of 38 (32 percent) had a subperiosteal abscess; 66 percent of
patients with subperiosteal abscess underwent surgery. ◊ The mean age is reported for all studies except for Seltz et
al[5]; this study reported the median age. § The ethmoid and maxillary sinuses were involved most commonly, but some
patients had frontal sinusitis and/or sphenoid sinusitis; many patients had involvement of multiple sinuses.
Orbital cellulitis Authors
Christopher Gappy, MD Steven M Archer, MD Michael Barza, MD Section Editors
Stephen B Calderwood, MD Morven S Edwards, MD Jonathan Trobe, MD Deputy Editor
Allyson Bloom, MD All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Sep 2015. | This topic last updated: Jun 24, 2015.
INTRODUCTION — Orbital cellulitis is an infection involving the contents of the orbit (fat and ocular muscles). I t must be
distinguished from preseptal cellulitis (sometimes called periorbital cellulitis), which is an infection of the anterior port ion of
the eyelid. Neither infection involves the globe itself.
Although preseptal and orbital cellulitis may be confused with one another because both can cause ocular pain and eyelid
swelling and erythema, they have very different clinical implications. Preseptal cellulitis is generally a mild condition that
rarely leads to serious complications, whereas orbital cellulitis may cause loss of vision and even loss of life. Orbital
cellulitis can usually be distinguished from preseptal cellulitis by its clinical features (ophthalmoplegia, pain with eye
movements, and proptosis) and by imaging studies; in cases in which the distinction is not clear, clinicians should treat
patients as though they have orbital cellulitis. Both conditions are more common in children than in adults, and preseptal
cellulitis is much more common than orbital cellulitis.
The pathogenesis, microbiology, clinical manifestations, complications, diagnosis, and treatment of orbital cellulitis will be
reviewed here. Preseptal cellulitis is discussed separately. Orbital infections caused by fungi, mainly the Mucorales
(which cause mucormycosis) and Aspergillus spp, and, much more rarely, Mycobacterium tuberculosis are also
presented separately. (See "Preseptal cellulitis" and "Mucormycosis (zygomycosis)" and "Epidemiology and clinical
manifestations of invasive aspergillosis" and "Tuberculosis and the eye".)
TERMINOLOGY — Preseptal cellulitis and orbital cellulitis involve different anatomic sites, with preseptal cellulitis
referring to infections of the soft tissues anterior to the orbital septum, and orbital cellulitis referring to infections posterior
to it (figure 1). Orbital cellulitis involves the muscle and fat located within the orbit. Orbital cellulitis does not involve the
globe. (See 'Anatomy' below and "Preseptal cellulitis", section on 'Anatomy'.)
There is some debate regarding the appropriate terminology for these infections. Some clinicians use the term "periorbital
cellulitis" rather than "preseptal cellulitis" or use the terms interchangeably. We prefer the term "preseptal cellulitis" to
make a clear distinction between this infection and the more serious infection, "orbital cellulitis." Orbital cellulitis is
sometimes referred to as "postseptal cellulitis"; we favor the term "orbital cellulitis," and will use it throughout this topic.
ANATOMY — Basic familiarity with the anatomy of the eye is fundamental to understanding the pathogenesis, clinical
manifestations, and complications of orbital cellulitis. The orbit is a cone-shaped structure, lying horizontally, with its apex
in the skull. It is surrounded by paranasal sinuses, namely, the frontal (lying superior), ethmoid (medial) and maxillary
(inferior) sinuses (figure 2). The orbit is lined by periosteum. The ethmoid sinuses are separated from the orbit by a paper-
thin layer called the lamina papyracea, which contains many perforations for nerves and blood vessels as well as some
natural fenestrations termed Zuckerkandl's dehiscences. The most common route of infection of the orbit is by extension
from the ethmoid sinuses, presumably through these perforations.
The orbital septum is a membranous sheet that extends from the periosteum of the orbit to the tarsal plate and forms the
anterior boundary of the orbital compartment (figure 1). The superior and inferior orbital veins drain blood directly into the
cavernous sinus (figure 3). Because of this communication and because the inferior orbital veins are valveless, infection
can pass readily from the orbit to intracranial structures [1].
EPIDEMIOLOGY AND PATHOGENESIS — Orbital cellulitis is much more common in young children than in older
children or adults. Orbital cellulitis is an uncommon complication of bacterial rhinosinusitis, but rhinosinusitis is the source
of most cases of orbital cellulitis; coexisting rhinosinusitis is present in 86 to 98 percent of cases of orbital cellulitis [2-5].
Ethmoid sinusitis and pansinusitis are the forms of rhinosinusitis most likely to lead to orbital cellulitis. (See "Acute
●Signs and symptoms should begin to show improvement within 24 to 48 hours following the initiation of appropriate
therapy; if this does not occur, repeat imaging should be performed and surgery should be considered.
(See 'Response to therapy' above.)
●For patients with uncomplicated orbital cellulitis, we suggest that antibiotics be continued until all signs of orbital
cellulitis have resolved, and for a total of at least two to three weeks (including both intravenous and oral therapy). A
longer period (at least four weeks) is recommended for patients with severe ethmoid sinusitis and bony destruction
of the sinus. The management of the complications of orbital cellulitis is discussed separately. (See 'Duration and
switch to oral therapy' above.)
●Although initial treatment may consist of intravenous antibiotics alone, management should be in consultation with
an ophthalmologist and an otolaryngologist because the physical examination requires
ophthalmic and/or otolaryngologic expertise and surgery is sometimes required. The main indications for surgery are
a poor response of the infection to antibiotic treatment, worsening visual acuity or pupillary changes, or evidence of
an abscess, especially a large abscess (>10 mm in diameter) or one that fails to respond promptly to antibiotic
treatment. (See 'Surgery' above.)
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