History and exam

Key diagnostic factors

common

presence of risk factors

Key risk factors include: childhood (especially male children); previous sinus infection; lack of Haemophilus influenzae type b (Hib) vaccination.

recent sinus infection

A well-known risk factor for both peri-orbital and orbital cellulitis.[1][9][10][11]​​[19]

recent eyelid injury

Eyelid injury can lead to a secondary skin infection and peri-orbital and/or orbital cellulitis.

redness and swelling of eye

Peri-orbital cellulitis usually presents as redness around the eyelid.[Figure caption and citation for the preceding image starts]: Swollen and red left eyelidFrom the personal collections of H. Jane Kim, MD, and Robert Kersten, MD, UCSF; used with permission [Citation ends].com.bmj.content.model.Caption@30e8ceb7

Orbital cellulitis usually presents as a severe redness around a swollen eyelid with ptosis.

ocular pain

Can be extremely severe, especially in orbital compartment syndrome, and is a key factor for orbital cellulitis.[1][9][10][11]​​

decreased vision

Visual disturbance is a key symptom of orbital cellulitis. Rarely present in peri-orbital cellulitis.

Rapidly declining vision may be a sign of developing orbital compartment syndrome, and is an indication for hospital admission.[1][9][10][11]​​

Visual loss is a sign of orbital cellulitis; occurs in up to 11% of cases.[10][18]

proptosis

Key factor for orbital cellulitis.

Severe proptosis is an indication for hospital admission.[10][20]

eyelid oedema

Eyelid oedema is one of the earliest signs of peri-orbital and orbital cellulitis.

Orbital oedema can lead to chemosis, proptosis, and visual disturbances.[1][9][10][11]​​

insect bite on eyelid

An insect bite on the eyelid or surrounding area is one of the more common causes of this condition. Insect bites can become infected with common pathogens and lead to peri-orbital cellulitis.

stye or chalazion

A stye or chalazion (or even a papule) on the eyelid or surrounding skin can rupture and become infected, leading to peri-orbital cellulitis.

uncommon

ear or facial infection

Can be the cause of this condition.[1][9][10][11]​​

ophthalmoplegia and diplopia

Key factor for orbital cellulitis. Rarely present in peri-orbital cellulitis.

Decreased eye mobility can be difficult to evaluate, so index of suspicion needs to be high.

Severe ophthalmoplegia is an indication for hospital admission as it may be a sign of cavernous sinus thrombosis.

Diplopia is not a common symptom, but may be present in orbital cellulitis.

Other diagnostic factors

common

orbital trauma

Can be the cause of this condition.

Penetrating traumas or orbital fractures are implicated in intra-orbital abscess formation.[1][9][10][11]​​

skin infection

Can be a cause, especially when preceded by an insect bite or inoculation from a penetrating injury.

chemosis

Occurs more commonly in orbital cellulitis, but cannot be used as a differentiating sign.

tenderness around eye

Present to some degree in all stages.[1][9][10][11]​​

fever

More common with orbital cellulitis.[1][9][10][11]​​

Should raise red flag if develops in peri-orbital cellulitis.

eyelid erythema

One of the early signs in both conditions.

elevated intra-ocular pressure

May be an early sign, especially in orbital cellulitis.[1][9][10][11]​​

headache

Can be one of the earliest signs, present mostly in orbital cellulitis.

malaise

Some patients may have constitutional symptoms such as malaise, but this mostly occurs in orbital cellulitis.

uncommon

previous dental infection or dental work

A dental problem can be the source of sinusitis, which in turn is the most common cause of orbital cellulitis.[27]

orbital fracture

Can be the cause of orbital cellulitis.

foreign body in eye or orbit

Can be a cause of trauma, which can lead to infection.[1]

drowsiness

Late sign, and indicates meningeal involvement.[10]

nausea/vomiting

Late sign, and indicates meningeal involvement.[1][9][10][11]​​

nasal discharge

May be purulent, especially late in disease.

Risk factors

strong

sinusitis

Bacterial sinusitis is the most common risk factor for both peri-orbital and orbital cellulitis. In diabetic and immunocompromised patients, there may be sinus infection with Mucor or invasive Aspergillus.[1][9][10][11]​​[19]

young age

More common in children than in adults.[1][9][10][11]​​

male sex

In childhood, it is more common in males than in females.[1][9][10][11]​​ In adulthood, the incidence is similar between sexes.

lack of Hib vaccine in children

Standard use of the Haemophilus influenzae type b (Hib) vaccine has significantly decreased the risk of pre-septal and orbital cellulitis in children.[4]

Use of this content is subject to our disclaimer