12-year-old boy with respiratory infection and a red, painful, swollen left eye
What is your diagnosis?
The diagnosis is...
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