What are the signs and symptoms of orbital cellulitis?

Signs and Symptoms of Orbital Cellulitis

Orbital cellulitis presents with eyelid or periocular swelling, proptosis, limitation of extraocular movements, and potential vision loss, requiring immediate diagnosis and treatment to prevent serious complications. 1

Clinical Presentation

• Eyelid erythema and edema (often severe and rapidly progressive) 1, 2
• Proptosis (forward displacement of the eye) 1, 3
• Limitation of extraocular movements/ophthalmoplegia 1, 4
• Chemosis (conjunctival swelling) 4, 3
• Pain with eye movement 2, 3
• Vision loss (can be a sign of serious complications) 2, 3
• Fever and headache 2, 5
• Diplopia (double vision) 2, 3

Distinguishing Features from Preseptal Cellulitis

• Preseptal cellulitis affects tissues anterior to the orbital septum, while orbital cellulitis involves tissues posterior to the orbital septum 1, 6
• Key differentiating features of orbital cellulitis include:
  • Proptosis (not present in preseptal cellulitis) 1, 3
  • Restriction of extraocular movements (not present in preseptal cellulitis) 1, 4
  • Vision loss (not typically seen in preseptal cellulitis) 2, 3
  • Conjunctival chemosis extending beyond the eyelid margins 4, 3

Common Etiologies

• Most commonly secondary to sinusitis, particularly ethmoid sinusitis 1, 4
• Can also result from:
  • Trauma to the eyelids 5, 3
  • External ocular infection 5, 3
  • Dental infections or procedures 3
  • Hematogenous spread from distant infections 2, 3

Diagnostic Considerations

• CT of the orbits with contrast is the initial imaging modality of choice for suspected orbital cellulitis 1

  • Helps differentiate preseptal from orbital (postseptal) cellulitis 1
  • Can identify complications such as subperiosteal abscess or bone erosion 1
  • Identifies adjacent sinus disease, which is often the source 1, 4

• MRI of the orbits is complementary to CT for evaluating:

  • Intra-orbital spread of infection 1
  • Intracranial extension or complications 1

Potential Complications

• Intra-orbital abscess formation 1, 3
• Cavernous sinus thrombosis 1, 3
• Optic nerve injury leading to vision loss 1, 3
• Retinal artery occlusion 1, 3
• Intracranial extension (meningitis, brain abscess) 4, 3
• Death (rare in the modern antibiotic era, but still possible) 2, 3

Clinical Pitfalls

• Clinical findings alone may not be specific enough to distinguish preseptal from orbital infections 1
• Inflammatory orbital pseudotumor (IOIS) and IgG4-related orbital disease can mimic orbital cellulitis clinically and radiologically 1, 7
• Severe viral conjunctivitis (particularly adenoviral) can present with marked eyelid swelling resembling preseptal cellulitis, which may be confused with early orbital cellulitis 6
• Delay in diagnosis and treatment significantly increases morbidity and mortality 4, 8

High-Risk Populations

• More common in the pediatric population 2, 4
• Individuals with sinusitis, particularly ethmoid sinusitis 1, 4
• Patients with recent trauma or surgery to the face or orbit 3
• Immunocompromised patients (at risk for fungal orbital cellulitis) 1