The complaint of “red eye” is frequently encountered in the Peds ED.  We have entertained some considerations with respect to Conjunctivitis (especially in neonates), but occasionally, instead of seeing the “red eye” we were expecting, we see a child who looks like Rocky Balboa.

Periorbital Cellulitis

Basics

• Occurs primarily in kids < 5 yrs
• Periorbital cellulitis is 3 times as common as orbital cellulitis.

Causes

• Rhinosinusitis (particularly related to the ethmoid sinus) is the most common cause
• Direct extension from local structure
  • Bug Bite
  • Stye
  • Dacryocystitis
  • Dental Abscess
  • Impetigo
  • Direct Trauma
  • Hematogenous Spread

Bugs

• Staphylococcus aureus and S. epidermidis and S. pyogenes are the primary culprits (~75% of cases) currently.
• MRSA should be considered based on your local resistance patterns.
• H. influenzae type b was, historically, the most common cause, but vaccination has greatly reduced it as a cause.

Clinical Findings

• Periorbital Cellulitis is a clinical diagnosis!
  • No lab value or radiology is needed to make the diagnosis
  • Unilateral eyelid swelling, redness, and/or warmth.
    • This can be very mild …
    • or quite severe to the point that the eyelids are swollen shut.
  • Tenderness may also be present.

• Features concerning for extension into the orbit (orbital cellulitis)
  • Blurred Vision (obtain a Visual Acuity!)
  • Proptosis
  • Restricted Range of Movement of the Eye
  • Chemosis
  • Increased intraorbital pressure

• In cases where the swelling prevents adequate examination of the eye, imaging with CT may be required to distinguish periorbital cellulitis from orbital cellulitis.
• Elevations in WBC count, CRP, and or ESR can imply orbital involvement, but they are not helpful enough to base your management on alone.

Management

• The source of the infection can help determine the best empiric antibiotic choice:
  • Rhinosinusitis – Augmentin, 2nd or 3rd generation cephalosporin
  • Dental abscess – Clindamycin or Augmentin
  • Stye – 1st generation cephalosporin, or Clindamycin if MRSA is a concern
  • Impetigo – Clindamycin or 1st generation cephalosporin
  • Hematogenous Spread – 3rd generation cephalosporin PLUS clindamycin or Vancomycin

• Simple (mild) periorbital cellulitis
  • Mostly just redness without eyelid swelling
  • May be started on oral antibiotics
  • Therapy is typically 7-10 days
  • These children should look clinically very well and have no signs of toxicity.
• All others
  • Intravenous antibiotics and hospitalization is appropriate.
  • If there is no improvement in 24 to 48 hours of therapy:
    • Reconsider the antibiotic coverage
    • Reconsider the diagnosis – is this really orbital cellulitis?
• Attempt to obtain cultures
  • Blood cultures are not often helpful… but ocular discharge cultures are!

When to Obtain CT?

• Eyelid swelling prevents adequate examination of the eye.
• CNS involvement (ophthalmoplegia, lethargy, seizure, focal deficits, etc.)
• Change in visual acuity
• Proptosis
• No improvement in 24 – 48 hours of appropriate therapy.
• Clinical deterioration

Hauser A, Fogarasi S. Periorbital and Orbital Cellulitis. Pediatrics in Review. 2010; 21; 242.

Al-Nammari S, Robertson B, Ferguson C. Should a child with preseptal periorbital cellulitis be treat with intravenous or oral antibiotics? BestBETs 2007.