Cellulitis periobital and orbital


These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

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To guide Emergency Department (ED) staff with the assessment and management of periorbital and orbital cellulitis.


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 - refer urgently to Ophthalmology if any of these signs are present

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

Likely organisms1

  • Streptococcus pyogenes
  • Streptococcus pneumoniae
  • Staphylococcus aureus
  • Haemophilus influenzae (HiB) 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 streptococcus pyogenes and staphylococcus aureus more likely. 



  • 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 of children < 1 month of age

Admit for IV cefotaxime - Neonatal Medication Monograph (PDF).

For patients <3 months perform eye swab for Gonorrhoea and Chlamydia

Management of children ≥ 1 months of age

Allergic reaction    Mild    Moderate   Severe/ophthalmological  emergency 
  (no sinusitis)  (with Sinusitis or HiB suspected)
  • Trial antihistamine
  • Admit under General Paediatrics
  • Commence IV Ceftriaxone
  • Computerised Tomography (CT)
  • Urgent ophthalmology consult
  • Urgent Ear, Nose and Throat (ENT) referral if sinusitis, abscess or cavernous sinus thrombosis
  • Bloods culture and full blood count.
  • Commence IV Vancomycin and Ceftriaxone

For dosing in children < 1 month, refer to Neonatal Medication Protocols.


  1. Gappy C, Archer SM and Barza M (2014) Orbital Cellulitis. UpToDate (external site).
  2. WA Health Child and Adolescent Health Service. ChAMP Eye Infections Paediatric Empiric Guidelines, October 2021

Endorsed by:  CAHS Drug and Therapeutics Committee  Date: Apr 2022

 Review date:  Apr 2025

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