Periorbital Cellulitis: Symptoms, Types, Causes and Treatment

Periorbital cellulitis is a potentially serious infection that affects the eyelid and surrounding tissues. Although it is most commonly seen in children, it can occur at any age. Prompt recognition and treatment are crucial, as periorbital cellulitis can sometimes progress to more severe conditions, including orbital cellulitis or even threaten vision and life if left untreated. In this comprehensive article, we will explore the symptoms, types, causes, and current treatments for periorbital cellulitis, synthesizing the latest research and clinical experience.

Symptoms of Periorbital Cellulitis

Periorbital cellulitis often starts with subtle signs that can rapidly progress. Recognizing the early symptoms is essential for timely intervention and prevention of complications.

Symptom	Description	Frequency/Significance	Source(s)
Swelling	Puffy, swollen eyelids and surrounding tissue	Most common, hallmark feature	2 3 6
Redness	Erythema of eyelid and periorbital skin	Common, key diagnostic clue	2 3 6
Tenderness	Pain or discomfort on touching the area	Often present, may vary in severity	2 3
Warmth	Increased skin temperature over area	Accompanies redness and swelling	2 3
Chemosis	Swelling of conjunctiva	Less common, may indicate progression	2 6
Discharge	Possible eye discharge (e.g., pus)	Occasional, especially with infections	1 8
Fever	Elevated body temperature	Variable; more common in children	1 3 6
Visual Changes	Blurred vision, pain with eye movement (suggests more severe disease)	Warning sign for orbital involvement	7

Table 1: Key Symptoms

Recognizing the Symptoms

Early diagnosis of periorbital cellulitis is largely based on recognizing the clinical features:

• Swelling and Redness: The infection typically presents as a sudden swelling and redness of the eyelid and adjacent skin. The area is often warm and tender to the touch. These classic signs are usually unilateral but can occasionally affect both eyes, especially in systemic infections 2 3 6.
• Fever: Systemic symptoms like fever may be present, especially in children. However, the absence of fever does not rule out an infection 1 3.
• Chemosis and Discharge: Swelling of the conjunctiva (chemosis) or discharge may occur, particularly if conjunctivitis or another local infection is present 1 8.
• Pain and Tenderness: Patients often report pain or discomfort in the affected area. In severe cases, pain may worsen with eye movement, raising concern for deeper (orbital) involvement 2 3 7.
• Visual Symptoms: Any signs of vision loss, double vision, severe pain with eye movement, or inability to open the eye fully are red flags for orbital cellulitis or more serious complications and require urgent medical attention 7.

Differentiating from Orbital Cellulitis

It is critical to distinguish periorbital cellulitis from orbital cellulitis, which is an infection of the tissues behind the orbital septum and can lead to permanent vision loss or life-threatening complications. Orbital cellulitis is more likely if the patient has proptosis (bulging of the eye), ophthalmoplegia (inability to move the eye), decreased vision, or severe pain with eye movements 6 7.

Types of Periorbital Cellulitis

Periorbital cellulitis is not a one-size-fits-all diagnosis. Understanding the different types can help tailor the approach to treatment and management.

Type	Location/Features	Distinguishing Factors	Source(s)
Preseptal	Anterior to orbital septum	Most common, less severe	2 3 6 5
Orbital (Postseptal)	Posterior to orbital septum	More severe, risk of vision loss	2 3 6 5
Necrotizing Fasciitis	Rapid, destructive infection	Dusky skin, rapid progression	7
Malignant Mimics	Tumors (e.g., lymphoma)	Rare, persistent, non-resolving case	1

Table 2: Types of Periorbital Cellulitis

Preseptal (Periorbital) Cellulitis

• Definition: Infection limited to the eyelid and tissues in front of the orbital septum 2 3 5 6.
• Features: Most common form; characterized by eyelid swelling, redness, and tenderness. Vision is usually unaffected, and eye movements are normal.
• Prognosis: Generally responds well to antibiotics and has a low risk of complications if treated promptly.

Orbital (Postseptal) Cellulitis

• Definition: Infection extends beyond the orbital septum into the orbit, affecting the eye and its muscle/fat 2 3 5 6.
• Features: More severe; symptoms include proptosis, pain with eye movement, ophthalmoplegia, and sometimes decreased vision.
• Management: Requires urgent intervention and often imaging (CT/MRI) to assess extent.

Necrotizing Fasciitis

• Definition: Rare, rapidly progressive, and destructive soft tissue infection involving the periorbital region 7.
• Features: Presents with dusky skin discoloration, severe pain, rapid tissue necrosis, and systemic toxicity.
• Urgency: Medical emergency—requires immediate surgical intervention and broad-spectrum antibiotics.

Malignant Mimics (e.g., Lymphoma)

• Definition: Rarely, malignancies such as nasal NK/T-cell lymphoma can mimic periorbital cellulitis 1.
• Features: May present with swelling, redness, and pain resembling infection but does not respond to antibiotics.
• Significance: Non-resolving, atypical presentations should prompt investigation for malignancy.

Causes of Periorbital Cellulitis

Understanding the underlying causes can help guide both prevention and treatment strategies. The cause often influences the severity and clinical course of the disease.

Cause/Source	Description	Prevalence/Notes	Source(s)
Local Infections	Conjunctivitis, chalazion, impetigo	Most common in children	8 2 3
Sinusitis	Especially ethmoid and maxillary	Major risk factor, especially for orbital cellulitis	3 6 13
Trauma/Injury	Eyelid cuts, insect bites, surgeries	Frequent in young children	8 3 11
Systemic Spread	Hematogenous from bacteremia	Rare in post-HIB vaccine era	8 11
Unusual Pathogens	MRSA, Bacillus thuringiensis, others	MRSA increasingly common	9 10
Malignancy	Nasal NK/T-cell lymphoma, others	Very rare	1

Table 3: Common Causes

Local and Regional Infections

• Conjunctivitis: The most frequent predisposing condition in children. Bacteria from an infected conjunctiva can invade the surrounding eyelid tissues 8.
• Sinusitis: Particularly ethmoid and maxillary sinusitis, is a major risk factor for periorbital and especially orbital cellulitis. Sinus infections can spread through thin bony walls into the orbit 3 6 13.
• Other Local Sources: Conditions like chalazion (blocked oil gland), dacryocystitis (infection of tear sac), impetigo, and dental infections can also serve as entry points for bacteria 2 8.

Trauma and Skin Injury

• Cuts, Insect Bites, and Surgery: Any breach in the skin barrier around the eye can introduce bacteria, leading to cellulitis. This is particularly common in young children who may scratch their faces or sustain minor injuries 3 8 11.

Systemic Spread (Bacteremia)

• In rare cases, especially before the widespread use of the Haemophilus influenzae type B (HIB) vaccine, periorbital cellulitis could result from bacteria spreading through the bloodstream (hematogenous spread) 8 11. This is now less common.

Unusual Pathogens and Antimicrobial Resistance

• Staphylococcus aureus (including MRSA): MRSA is now a leading cause of periorbital cellulitis in many regions 9. Streptococcus species also remain important 3 5.
• Rare Pathogens: Bacillus thuringiensis and other unusual organisms may occasionally cause periorbital cellulitis, especially in immunocompromised individuals or after trauma 10.
• Malignancy: Rarely, malignancies (e.g., NK/T-cell lymphoma) can mimic periorbital cellulitis and should be suspected in cases unresponsive to antibiotics 1.

Treatment of Periorbital Cellulitis

Effective management of periorbital cellulitis is essential to prevent complications. Treatment strategies may vary depending on the cause, severity, and risk factors.

Treatment	Approach/Details	Indication/Outcome	Source(s)
Antibiotics	Empiric IV/oral targeting MRSA, Strep	First-line in most cases	3 6 9 11
Imaging (CT/MRI)	Evaluate orbital involvement/abscess	If severe, not improving, or orbital signs	6 12 13
Surgery	Drain abscess, necrotic tissue	For abscess, necrotizing fasciitis, failed medical therapy	6 7 13
Steroids	Adjunct in some cases	Use in selected orbital cases	5 9
Supportive Care	Analgesia, hydration, monitoring	All patients	6 12

Table 4: Treatment Options

Antibiotic Therapy

• Empiric Coverage: Most cases are treated with empiric antibiotics that cover Staphylococcus aureus (including MRSA) and Streptococcus species 3 6 9 11.
• IV vs. Oral: Intravenous antibiotics are used for moderate to severe cases, young children, or those unable to tolerate oral medication. Oral antibiotics may be appropriate for mild cases in older children/adults with close follow-up 6 12.
• Duration: Treatment typically lasts 7–14 days, adjusted based on clinical response 3 6 11.
• Antibiotics of Choice: Amoxicillin-clavulanic acid is commonly used; clindamycin or vancomycin may be added for MRSA coverage 6 9.

Imaging and Specialist Assessment

• When to Image: CT or MRI is recommended if orbital cellulitis is suspected, if symptoms worsen or fail to improve after 24–48 hours, or if there is concern for abscess formation 6 12 13.
• Purpose: Imaging helps differentiate preseptal from orbital cellulitis and identify complications such as abscess or intracranial spread 12 13.

Surgical Intervention

• Indications: Surgery is reserved for cases with abscess (e.g., subperiosteal or orbital abscess), necrotizing fasciitis, or when there is no response to antibiotics 6 7 13.
• Procedures: May include drainage of pus, removal of necrotic tissue, or even enucleation (removal of the eye) in extreme cases 7 13.

Adjunctive Therapies

• Steroids: May be used as adjunct therapy in select cases of orbital cellulitis to reduce inflammation, but evidence is mixed and should be reserved for specialist settings 5 9.
• Supportive Care: Includes pain control, hydration, and careful monitoring for signs of deterioration 6 12.

Outcomes and Prognosis

• Most patients recover fully with early diagnosis and appropriate treatment 6 12.
• Complications: Delayed treatment can result in vision loss, intracranial infection, or systemic sepsis, underscoring the need for vigilance and prompt care 6 13.

Conclusion

Periorbital cellulitis is a common but potentially serious infection that requires prompt recognition and management.

Key points to remember:

• Symptoms: Swelling, redness, tenderness, and sometimes fever are common. Visual changes or pain with eye movement require urgent assessment.
• Types: Most cases are preseptal, but clinicians must differentiate from the more dangerous orbital cellulitis and rare necrotizing fasciitis.
• Causes: Commonly arise from local infections (conjunctivitis, sinusitis), trauma, or less often, systemic spread; MRSA is an increasing concern.
• Treatment: Early antibiotics are critical; imaging and surgery are reserved for severe or complicated cases. Most patients have excellent outcomes with timely intervention.

Awareness of the evolving causes, emerging resistant organisms, and the need for careful assessment will ensure the best outcomes for patients with periorbital cellulitis.