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  • 12-year-old boy with respiratory infection and a red, painful, swollen left eye

    What is your diagnosis?

    The diagnosis is...

    Photo of young person with swelling of the left upper and lower eyelids

    The image is consistent with a diagnosis of orbital cellulitis.

    • Orbital cellulitis is an infection of the soft tissues of the eye socket (orbit).
    • The orbital septum is a fascial plane separating the eyelid from the orbit, which includes the intraorbital fat and intraocular muscles.
    • Preseptal cellulitis involves just the eyelid; orbital cellulitis includes infection posterior to the septum into the orbit.
    • Treatment, causes, and outcomes of preseptal and orbital cellulitis vary.
    • Generally, a preseptal cellulitis (infection of the eyelid) is caused by a skin infection of the eyelid, whereas an orbital cellulitis is caused by a dental, upper airway or more systemic infection. However, preseptal cellulitis may also be caused by a systemic infection.

    What is the role of the primary care or emergency medicine physician?

    • Primary care and emergency physicians must distinguish between preseptal and orbital cellulitis.
    • If orbital cellulitis is suspected, physicians should consider imaging the sinuses and orbits.
    • An ophthalmology consultation should be considered for thorough evaluation of the eye and characterization of the patient’s vision.
    • Intravenous antibiotics are often needed in both the pediatric and adult populations.
    • Adult cases have broader infectious agents and more often require surgical intervention. Some pediatric cases also require surgery.

    What is the role of the ophthalmologist?

    • Identify orbital cellulitis based on symptoms and examination.
    • Collaborate with internal medicine or pediatrics, otolaryngology, and other services to get sinus and blood cultures when appropriate.
    • Ensure that patients receive broad-spectrum intravenous antibiotics.
    • Document improvement in the clinical examination with examinations at least 1-2 times daily.
    • Consider obtaining imaging of the orbit if the patient does not respond to initial antibiotic intervention or to differentiate between preseptal and orbital cellulitis.
    • Consider surgical drainage of abscesses within the orbit.

    What is the treatment?

    • Treatment of orbital cellulitis is broad-spectrum antibiotics. 
    • Surgical intervention with drainage of orbital abscesses and sinuses may be necessary.
    • Signs prompting surgical intervention include:
      • Signs of vision impairment; 
      • Increasing proptosis;
      • Decreasing ocular motility;
      • Lack of response within 48 hours of antibiotic treatment.

    Learn more: Ophthalmology resources for medical students

    Interactive Case: Pediatric Ophthalmology

    Medical Knowledge Video: External Causes of Red Eye

    Interactive Figure: Cross section of the eye and the orbit

    Careers in Ophthalmology Video Series: Pediatric Ophthalmology

    Guide to the Eye Examination Video:  Pediatric Eye Examination