What are periorbital and orbital cellulitis?
Periorbital and orbital cellulitis are both serious infections around the eye. They can occur at any age but are more common in children. The infections are caused by bacteria that can enter the skin and soft tissue of the eyelid from the bloodstream or from nearby infections, such as in the sinuses or upper teeth. Bacteria can also enter the skin from a cut or insect bite. Both periorbital and orbital cellulitis require antibiotic treatment.
What is the difference between periorbital and orbital cellulitis?
The difference between periorbital and orbital cellulitis depends on the location of the infection. Periorbital cellulitis is an infection that affects only the skin and soft tissue of the eyelid and around the eye. It is usually a milder infection than orbital cellulitis. The infection does not extend past a membrane called the orbital septum.
In orbital cellulitis, the infection involves deeper structures around the eye beyond the orbital septum. This may include the bone around the eye (the orbit), the muscles that control the eye, and fat and soft tissue that surround the eye.
Signs and symptoms of periorbital cellulitis
Children with periorbital cellulitis may have:
- fever
- one swollen, red eyelid
- eye pain
- fussiness
- difficulty opening the eye
- nasal congestion or recent viral infection
- eye redness
- eye discharge or a teary eye
- tooth pain and gum swelling
- a recent cut or insect bite on or near the eye
Signs and symptoms of orbital cellulitis
Children with orbital cellulitis may have any of the above as well as:
- pain when moving the affected eye
- difficulty seeing
- blurry or double vision
- an eye that bulges out
What causes periorbital and orbital cellulitis?
Both infections are most often caused by bacteria. Bacteria entering through a cut in the skin or a bug bite near or on the eyelid can lead to periorbital cellulitis. The swelling can also spread from another location, such as a dental abscess in an upper tooth or through the bloodstream. The most common source of infection leading to periorbital cellulitis and orbital cellulitis is a sinus infection.
How are periorbital and orbital cellulitis diagnosed?
A health-care provider can often diagnose periorbital or orbital cellulitis by examining your child. If swelling or pain prevents your child from opening their eyelid so the eye can be examined, it is sometimes difficult for the health-care team to complete a full assessment of the eye. A CT scan can help the health-care team confirm the location and extent of the infection.
Except in cases of very mild swelling in children who appear well, children with periorbital and orbital cellulitis often also have blood tests to help diagnose the infection.
How are periorbital and orbital cellulitis treated?
Admission to hospital
Unless your child has a very mild periorbital cellulitis, appears very well and can be treated with oral antibiotics, children will require admission to hospital. Treatment of periorbital cellulitis and orbital cellulitis often involves the collaboration of a large health-care team that includes a paediatrician, an ear, nose and throat (ENT) surgeon and an ophthalmologist. Other specialists may also be consulted if your child is diagnosed with a complication.
Medication and fluids
The main treatment for periorbital and orbital cellulitis is antibiotics. Antibiotics are given intravenously (IV) for all children with orbital cellulitis and most children with periorbital cellulitis until the redness and swelling improves, fever stops and eye pain and bulging are gone. While most children can take oral antibiotics to complete their treatment at home, some children will need prolonged IV antibiotics. Treatment plans depend on the type of bacteria that caused the infection and if your child experienced specific complications.
When sinusitis is suspected as a cause of periorbital or orbital cellulitis, nasal sprays are also added to help the sinuses drain.
Children who are too sick to drink or who are vomiting may receive fluids through an IV until they are feeling better and their drinking improves.
Some children require medication for pain or fever.
Surgery
Children who are not improving with antibiotics or who have developed an abscess may require surgery to drain the abscess or clear the infection from the sinuses.
What are the possible complications of periorbital and orbital cellulitis?
Abscess
An abscess is a collection of bacteria and pus in a location that is difficult for antibiotics to reach. Abscesses can develop along the bones of the orbit or skull, near the sinuses, in the soft tissue of the eyelid, or in the brain. Depending on the size and location of the abscess, some children may need surgery to drain the bacteria and pus.
Vision loss
Several complications of orbital cellulitis can cause temporary or permanent vision loss, such as:
- pressure on the eye and its blood vessels from swelling
- inflammation or clots of the main blood vessels of the eye
- inflammation of the optic nerve
Close monitoring and treatment of children with orbital cellulitis is key to identifying and treating these complications.
Thrombosis (blood clots)
The swelling and inflammation seen in severe infections can affect blood flow in blood vessels. A change in blood flow can lead to blood clots. In orbital cellulitis, thrombosis can occur in the main vessels of the eye (affecting vision) as well as the blood vessels in the brain. Thrombosis often requires added treatment.
Intracranial extension
The bacteria causing orbital cellulitis and (less commonly) periorbital cellulitis can spread through the blood supply or through the bone. The infection can spread, leading to meningitis or an abscess in the brain. Infection that spreads in this manner requires longer treatment.
Follow-up care
Some of the known complications of periorbital and orbital cellulitis, especially those related to spread of infection to the brain or blood clot formation, require longer treatment and regular follow-up.
Long-term effects of periorbital and orbital cellulitis
While extremely rare, some of these complications can lead to long-term effects, including vision loss and damage to the brain. However, the vast majority of children who are treated for periorbital and orbital cellulitis improve completely and have no long-term effects from the infection.
Take your child to their health-care provider if:
- your child has redness or swelling around an eye
Take your child to the nearest Emergency Department if your child has redness or swelling around the eye and:
- the swelling or pain is worsening or not improving while on oral antibiotics
- they have pain when moving the eye
- their eye is bulging out
- they complain of vision problems
- they appear very unwell