Cellulitis periobital and orbital

Aim

To guide staff with the assessment and management of periorbital and orbital cellulitis.

Background

Orbital cellulitis

Several conditions can present in a similar way, but all of these are ophthalmological emergencies and are approached in the same way:

  • Orbital cellulitis
  • Orbital abscess
  • Subperiosteal abscess
  • Cavernous sinus thrombosis.

Key signs

  • Decreased visual acuity
  • Proptosis
  • Ophthalmoplegia
  • Red eye
  • Papilloedema, meningism or cranial nerve involvement. Consider cavernous sinus thrombosis.

Likely organisms

  • Streptococcus pyogenes
  • Streptococcus pneumoniae
  • Staphylococcus aureus
  • Haemophilus influenzae in unimmunised children

Periorbital cellulitis

  • This involves pre-septal soft tissue infection. Likely infections are the same as for cellulitis, but the presence of a contiguous skin lesion (insect bite, scratch etc.) makes S. pyogenes and S. aureus more likely. 

Assessment

Severity

  • The assessment of the severity of the presentation will determine the management.
Consider Allergic reaction    Mild     Moderate   Severe/ophthalmological  emergency 
  • Localised swelling
  • No tenderness
  • No redness
  • Afebrile
  • Mild redness and swelling
  • Systemically well 
  • Moderate redness and swelling
  • +/- systemically unwell
  • Decreased visual acuity
  • Proptosis
  • Ophthalmoplegia
  • Red eye

Management

Please speak to the Clinical Microbiologist or Infectious Diseases for advice regarding management of children < 3 months of age with mild to severe periorbital cellulitis.

Management of children ≥ 3 months of age

Allergic reaction    Mild    Moderate   Severe/ophthalmological  emergency 
  • Trial antihistamine
  • Oral - Amoxycillin/clavulanic acid
  • Antibiotics
  • ED/GP review within 24 hours 
  • Admit
  • Commence IV Flucloxacillin and Ceftriaxone
  • Antibiotics 
  • CT
  • Urgent ophthalmology consult
  • Urgent ENT referral if abscess or cavernous sinus thrombosis
  • Blood culture and FBC
  • Commence IV Vancomycin and Ceftriaxone
  • Antibiotics

Bibliography

  1. Gappy C, Archer SM and Barza M (2014) Orbital Cellulitis. UpToDate (external site).
  2. WA Health Child and Adolescent Health Service. Eyes ChAMP Empiric Guidelines Version 1, December 2013.


Endorsed by:  Director, Emergency Department   Date:  Jun 2018


 Review date:   Feb 2020


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