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Orbital cellulitis

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


Orbital cellulitis is an infection involving the contents of the orbit (fat and ocular muscles). It must be distinguished from preseptal cellulitis (sometimes called periorbital cellulitis), which is an infection of the anterior portion 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".)


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.

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Literature review current through: Nov 2017. | This topic last updated: Nov 03, 2017.
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  1. Zhang J, Stringer MD. Ophthalmic and facial veins are not valveless. Clin Exp Ophthalmol 2010; 38:502.
  2. 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.
  3. Seltz LB, Smith J, Durairaj VD, et al. Microbiology and antibiotic management of orbital cellulitis. Pediatrics 2011; 127:e566.
  4. Nageswaran S, Woods CR, Benjamin DK Jr, et al. Orbital cellulitis in children. Pediatr Infect Dis J 2006; 25:695.
  5. Sobol SE, Marchand J, Tewfik TL, et al. Orbital complications of sinusitis in children. J Otolaryngol 2002; 31:131.
  6. Weakley DR. Orbital cellulitis complicating strabismus surgery: a case report and review of the literature. Ann Ophthalmol 1991; 23:454.
  7. Allen MV, Cohen KL, Grimson BS. Orbital cellulitis secondary to dacryocystitis following blepharoplasty. Ann Ophthalmol 1985; 17:498.
  8. McLeod SD, Flowers CW, Lopez PF, et al. Endophthalmitis and orbital cellulitis after radial keratotomy. Ophthalmology 1995; 102:1902.
  9. Varma D, Metcalfe TW. Orbital cellulitis after peribulbar anaesthesia for cataract surgery. Eye (Lond) 2003; 17:105.
  10. Hofbauer JD, Gordon LK, Palmer J. Acute orbital cellulitis after peribulbar injection. Am J Ophthalmol 1994; 118:391.
  11. Malik NN, Goh D, McLean C, Huchzermeyer P. Orbital cellulitis caused by Peptostreptococcus. Eye (Lond) 2004; 18:643.
  12. Chaudhry IA, Shamsi FA, Elzaridi E, et al. Outcome of treated orbital cellulitis in a tertiary eye care center in the middle East. Ophthalmology 2007; 114:345.
  13. Schmitt NJ, Beatty RL, Kennerdell JS. Superior ophthalmic vein thrombosis in a patient with dacryocystitis-induced orbital cellulitis. Ophthal Plast Reconstr Surg 2005; 21:387.
  14. Ataullah S, Sloan B. Acute dacryocystitis presenting as an orbital abscess. Clin Exp Ophthalmol 2002; 30:44.
  15. Allan BP, Egbert MA, Myall RW. Orbital abscess of odontogenic origin. Case report and review of the literature. Int J Oral Maxillofac Surg 1991; 20:268.
  16. Rubinstein JB, Handler SD. Orbital and periorbital cellulitis in children. Head Neck Surg 1982; 5:15.
  17. Weber AL, Mikulis DK. Inflammatory disorders of the paraorbital sinuses and their complications. Radiol Clin North Am 1987; 25:615.
  18. Goytia VK, Giannoni CM, Edwards MS. Intraorbital and intracranial extension of sinusitis: comparative morbidity. J Pediatr 2011; 158:486.
  19. Uzcátegui N, Warman R, Smith A, Howard CW. Clinical practice guidelines for the management of orbital cellulitis. J Pediatr Ophthalmol Strabismus 1998; 35:73.
  20. Schramm VL Jr, Curtin HD, Kennerdell JS. Evaluation of orbital cellulitis and results of treatment. Laryngoscope 1982; 92:732.
  21. Swift AC, Charlton G. Sinusitis and the acute orbit in children. J Laryngol Otol 1990; 104:213.
  22. Mills R. Orbital and periorbital sepsis. J Laryngol Otol 1987; 101:1242.
  23. Dudin A, Othman A. Acute periorbital swelling: evaluation of management protocol. Pediatr Emerg Care 1996; 12:16.
  24. McKinley SH, Yen MT, Miller AM, Yen KG. Microbiology of pediatric orbital cellulitis. Am J Ophthalmol 2007; 144:497.
  25. Kobayashi D, Givner LB, Yeatts RP, et al. Infantile orbital cellulitis secondary to community-associated methicillin-resistant Staphylococcus aureus. J AAPOS 2011; 15:208.
  26. Starkey CR, Steele RW. Medical management of orbital cellulitis. Pediatr Infect Dis J 2001; 20:1002.
  27. Chou SY, Tsai CC, Kau SC, et al. Aeromonas hydrophila orbital cellulitis in a patient with myelodysplastic syndrome. J Chin Med Assoc 2004; 67:51.
  28. Maccheron LJ, Groeneveld ER, Ohlrich SJ, et al. Orbital cellulitis, panophthalmitis, and ecthyma gangrenosum in an immunocompromised host with pseudomonas septicemia. Am J Ophthalmol 2004; 137:176.
  29. Hemady R, Zimmerman A, Katzen BW, Karesh JW. Orbital cellulitis caused by Eikenella corrodens. Am J Ophthalmol 1992; 114:584.
  30. 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.
  31. Barone SR, Aiuto LT. Periorbital and orbital cellulitis in the Haemophilus influenzae vaccine era. J Pediatr Ophthalmol Strabismus 1997; 34:293.
  32. Sharma A, Liu ES, Le TD, et al. Pediatric orbital cellulitis in the Haemophilus influenzae vaccine era. J AAPOS 2015; 19:206.
  33. Harris GJ. Subperiosteal abscess of the orbit. Age as a factor in the bacteriology and response to treatment. Ophthalmology 1994; 101:585.
  34. Brook I, Frazier EH. Microbiology of subperiosteal orbital abscess and associated maxillary sinusitis. Laryngoscope 1996; 106:1010.
  35. Chawla B, Sharma S, Kashyap S, et al. Primary orbital mycosis in immunocompetent infants. J AAPOS 2011; 15:211.
  36. Jones J, Katz SE, Lubow M. Scedosporium apiospermum of the orbit. Arch Ophthalmol 1999; 117:272.
  37. Durand, ML. Periocular infections. In: Principles and Practice of Infectious Diseases, 7th ed, Mandell, GL, Bennett, JE, Dolin, R (Eds), Churchill Livingstone Elsevier, Philadelphia 2010. p.1569.
  38. Rudloe TF, Harper MB, Prabhu SP, et al. Acute periorbital infections: who needs emergent imaging? Pediatrics 2010; 125:e719.
  39. Patt BS, Manning SC. Blindness resulting from orbital complications of sinusitis. Otolaryngol Head Neck Surg 1991; 104:789.
  40. Osguthorpe JD, Hochman M. Inflammatory sinus diseases affecting the orbit. Otolaryngol Clin North Am 1993; 26:657.
  41. Okamoto Y, Hiraoka T, Okamoto F, Oshika T. A case of subperiosteal abscess of the orbit with central retinal artery occlusion. Eur J Ophthalmol 2009; 19:288.
  42. Komolafe OO, Ashaye AO. Combined central retinal artery and vein occlusion complicating orbital cellulitis. Niger J Clin Pract 2008; 11:74.
  43. Ryan JT, Preciado DA, Bauman N, et al. Management of pediatric orbital cellulitis in patients with radiographic findings of subperiosteal abscess. Otolaryngol Head Neck Surg 2009; 140:907.
  44. Harris GJ. Age as a factor in the bacteriology and response to treatment of subperiosteal abscess of the orbit. Trans Am Ophthalmol Soc 1993; 91:441.
  45. Filips RF, Liudahl JJ. Asymptomatic posterior orbital cellulitis resulting from ethmoid/maxillary sinusitis. J Am Optom Assoc 1997; 68:55.
  46. Greenberg MF, Pollard ZF. Medical treatment of pediatric subperiosteal orbital abscess secondary to sinusitis. J AAPOS 1998; 2:351.
  47. Bergin DJ, Wright JE. Orbital cellulitis. Br J Ophthalmol 1986; 70:174.
  48. Reynolds DJ, Kodsi SR, Rubin SE, Rodgers IR. Intracranial infection associated with preseptal and orbital cellulitis in the pediatric patient. J AAPOS 2003; 7:413.
  49. Jacobs D, Galetta S. Diagnosis and management of orbital pseudotumor. Curr Opin Ophthalmol 2002; 13:347.
  50. Sirbaugh PE. A case of orbital pseudotumor masquerading as orbital cellulitis in a patient with proptosis and fever. Pediatr Emerg Care 1997; 13:337.
  51. Russo G, Di Pietro M, La Spina M. Ocular involvement in neuroblastoma: not always metastasis. Lancet Oncol 2004; 5:324.
  52. Shields CL, Shields JA, Honavar SG, Demirci H. Primary ophthalmic rhabdomyosarcoma in 33 patients. Trans Am Ophthalmol Soc 2001; 99:133.
  53. Mullaney PB, Karcioglu ZA, Huaman AM, al-Mesfer S. Retinoblastoma associated orbital cellulitis. Br J Ophthalmol 1998; 82:517.
  54. Rubinstein A, Riddell CE. Posterior scleritis mimicking orbital cellulitis. Eye (Lond) 2005; 19:1232.
  55. Abou-Rayyah Y, Rose GE, Konrad H, et al. Clinical, radiological and pathological examination of periocular dermoid cysts: evidence of inflammation from an early age. Eye (Lond) 2002; 16:507.
  56. Ziakas NG, Boboridis K, Gratsonidis A, et al. Wegener's granulomatosis of the orbit in a 5-year-old child. Eye (Lond) 2004; 18:658.
  57. Youssef Z, Pennefather PM, Watts MT. Orbital cellulitis vs allergic reaction to hyaluronidase as the cause of periorbital oedema. Eye (Lond) 2005; 19:691.
  58. Patil B, Agius-Fernandez A, Worstmann T. Hyaluronidase allergy after peribulbar anesthesia with orbital inflammation. J Cataract Refract Surg 2005; 31:1480.
  59. Hegde V, Smith G, Choi J, Pagliarini S. A case of gonococcal kerato-conjunctivitis mimicking orbital cellulitis. Acta Ophthalmol Scand 2005; 83:511.
  60. Ruttum MS, Ogawa G. Adenovirus conjunctivitis mimics preseptal and orbital cellulitis in young children. Pediatr Infect Dis J 1996; 15:266.
  61. Eustis HS, Mafee MF, Walton C, Mondonca J. MR imaging and CT of orbital infections and complications in acute rhinosinusitis. Radiol Clin North Am 1998; 36:1165.
  62. Howe L, Jones NS. Guidelines for the management of periorbital cellulitis/abscess. Clin Otolaryngol Allied Sci 2004; 29:725.
  63. Mair MH, Geley T, Judmaier W, Gassner I. Using orbital sonography to diagnose and monitor treatment of acute swelling of the eyelids in pediatric patients. AJR Am J Roentgenol 2002; 179:1529.
  64. Mahalingam-Dhingra A, Lander L, Preciado DA, et al. Orbital and periorbital infections: a national perspective. Arch Otolaryngol Head Neck Surg 2011; 137:769.
  65. Zyvox (linezolid) prescribing information. Pharmacia & Upjohn Company. Revised June 2010. http://www.pfizer.com/files/products/uspi_zyvox.pdf (Accessed on August 19, 2011).
  66. 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.
  67. Givner LB. Periorbital versus orbital cellulitis. Pediatr Infect Dis J 2002; 21:1157.
  68. Nelson LB, Olitsky SE. Disorders of the orbit. In: Harley's Pediatric Ophthalmology, Lippincott Williams and Wilkins, Philadelphia 2005. p.389.
  69. Youssef OH, Stefanyszyn MA, Bilyk JR. Odontogenic orbital cellulitis. Ophthal Plast Reconstr Surg 2008; 24:29.
  70. Todman MS, Enzer YR. Medical management versus surgical intervention of pediatric orbital cellulitis: the importance of subperiosteal abscess volume as a new criterion. Ophthal Plast Reconstr Surg 2011; 27:255.
  71. Rahbar R, Robson CD, Petersen RA, et al. Management of orbital subperiosteal abscess in children. Arch Otolaryngol Head Neck Surg 2001; 127:281.
  72. Arjmand EM, Lusk RP, Muntz HR. Pediatric sinusitis and subperiosteal orbital abscess formation: diagnosis and treatment. Otolaryngol Head Neck Surg 1993; 109:886.
  73. Pelton RW, Smith ME, Patel BC, Kelly SM. Cosmetic considerations in surgery for orbital subperiosteal abscess in children: experience with a combined transcaruncular and transnasal endoscopic approach. Arch Otolaryngol Head Neck Surg 2003; 129:652.
  74. Younis RT, Lazar RH, Bustillo A, Anand VK. Orbital infection as a complication of sinusitis: are diagnostic and treatment trends changing? Ear Nose Throat J 2002; 81:771.
  75. Tanna N, Preciado DA, Clary MS, Choi SS. Surgical treatment of subperiosteal orbital abscess. Arch Otolaryngol Head Neck Surg 2008; 134:764.