Condition

Orbital Cellulitis

Editors: J Martin Rodriguez MD, FACP, FIDSA; Amir Qaseem MD, PhD, MHA, MRCP (London), FACP; Paritosh Prasad MD

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Background Information

Description

  • Orbital cellulitis is an infectious inflammation of the tissues posterior to the orbital septum within the bony orbit characterized by acute onset and rapid progression.,,,
  • It is less common than preseptal cellulitis, a superficial infection limited to the tissues anterior to the orbital septum.,,,

Also Called

  • Postseptal cellulitis

Types

  • Chandler classification:
    • The Chandler classification organizes orbital complications of acute sinusitis into 5 groups based on the location and severity of infection.
      • Group 1: preseptal cellulitis, which is characterized by inflammatory edema including swelling of the eyelid anterior to the orbital septum. The area may be nontender without any other ocular signs or symptoms.
      • Group 2: orbital cellulitis, which is characterized by edema of the orbital tissues posterior to the orbital septum, including fat and ocular muscles. Orbital cellulitis may be associated with proptosis, chemosis, limited eye movements, and visual disturbance.
      • Group 3: subperiosteal abscess, which is an abscess between the orbit and the sinus periosteum. Symptoms may include vision loss and proptosis.
      • Group 4: orbital abscess, which is associated with complete ophthalmoplegia, vision loss, and proptosis.
      • Group 5: cavernous sinus thrombosis (CST), which is associated with bilateral proptosis and periorbital edema. Late signs of infection may include ophthalmoplegia, loss of vision, and meningismus.
    • There may not be a sequential progression from one group to the next, but each group represents an increased risk of vision loss and systemic morbidity.
    • Reference - ,, Laryngoscope 1970 Sep;80(9):1414, commentary can be found in Laryngoscope 1997 Apr;107(4):441

Epidemiology

Who Is Most Affected

  • Orbital cellulitis affects all age groups but is more common in children.,,
  • The reported mean age of children affected by orbital cellulitis is 7 years.
  • There is a reported male predominance of 2:1.,

Incidence/Prevalence

  • Orbital cellulitis is uncommon.
    • Among 110 patients with periorbital cellulitis in India between 1998 and 2006, 33 patients (30%) had orbital cellulitis and 77 patients (70%) had preseptal cellulitis in a retrospective cohort study (Indian J Ophthalmol 2011 Nov-Dec;59(6):431).
    • The annual incidence of orbital cellulitis was 9.3 per 100,000 children in India in 2019.
    • STUDY SUMMARY
      incidence of orbital cellulitis 1.6 per 100,000 children and 0.1 per 100,000 adults and adolescents in Scotland
      COHORT STUDY: Br J Ophthalmol 2014 Nov;98(11):1575

  • The incidence of periorbital cellulitis has decreased with the increase in vaccine coverage of common causative organisms such as Haemophilus influenzae type b (Hib) and Streptococcus pneumoniae.,,,
    • STUDY SUMMARY
      introduction of H. influenzae B vaccination associated with reduced annual case rate of Hib-related preseptal and orbital cellulitis
      COHORT STUDY: Ophthalmology 2000 Aug;107(8):1450

    • STUDY SUMMARY
      introduction of pneumococcal vaccine PCV7 associated with reduced rates of S. pneumoniae and viridans streptococcal isolation in patients with orbital cellulitis, and increased rates of Staphylococcus aureus
      COHORT STUDY: JAMA Otolaryngol Head Neck Surg 2013 Mar;139(3):223

  • In temperate climates, orbital cellulitis occurs more frequently during the winter months due to the association with sinusitis and upper respiratory tract infections.,,

Risk Factors

  • Risk factors for orbital cellulitis include:,,
    • Acute sinusitis in children and adolescents and in adults, particularly when infection originates in ethmoid or maxillary sinus
    • Upper respiratory infection
    • Odontogenic or dental infection
    • Trauma to the periorbital area or sinuses (such as orbital fracture)
    • Presence of a foreign body such as organic or metal objects
    • Ophthalmic surgery, particularly in low-income countries
  • Anatomical characteristics such as thin medial orbital wall, valveless veins of the orbit, foramina of the orbital bones, and lack of lymphatics may contribute to increased risk of orbital cellulitis in patients with sinusitis.,
  • STUDY SUMMARY
    orbital cellulitis commonly associated with sinus infection, with anterior ethmoid and maxillary sinuses most commonly involved sinuses
    COHORT STUDY: Int J Pediatr Otorhinolaryngol 2008 Mar;72(3):377

  • STUDY SUMMARY
    sinus disease and trauma most frequent causes of orbital cellulitis
    COHORT STUDY: Ophthalmology 2007 Feb;114(2):345

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