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

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.

• 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.

• 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.

• 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.

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