Periorbital cellulitis is more than meets the eye
A collective gasp went up as the patient poked his head into the staff work area. The poor little guy looked like a toddler Rocky after his final round in the ring. But instead of looking bruised, purple and puffy, his left eye was surrounded by hard, angry, red swelling.
My pediatric partner checked him in an exam room and, suspecting a serious eye infection rather than the more commonly seen allergic reaction of the eyelid, sent the boy and his mother on to the emergency department for further work up.
Thankfully, CT scan showed that though the boy was indeed suffering from an infectious process, the affected region was periorbital and not orbital, sparing the eye itself.
In an article in Pediatrics in Review, pediatric hospitalists Andrea Hauser and Simone Fogarasi explain that periorbital cellulitis (also known as preseptal cellulitis) is a bacterial infection of the eyelids and other soft tissues surrounding, but still in front of, the level of the eyeball.
A thin membrane, the orbital septum, sits right behind the eyelids and blocks most of these superficial infections from passing deep into the vulnerable orbit.
The two physicians report that periorbital cellulitis is usually seen in the pediatric age group, particularly in children younger than 5. This condition is often the result of infection spreading from nearby sources such as a sty, sinusitis, dental abscess, and skin breakdown (as from an infected insect bite), or due to bacterial dissemination through the bloodstream.
In their sinusitis practice guideline published in the journal Pediatrics, Dr. Ellen Wald and colleagues note that the most common complications of acute pediatric sinusitis are periorbital and orbital infections.
Most of these infections follow acute ethmoid — the small sinus cavities located between the nose and eyes — sinusitis in generally healthy youngsters.
It's not always easy to differentiate periorbital from orbital infections on initial exam since, as Hauser and Fogarasi caution, redness, swelling, warmth, and tenderness of the eyelid can be present in both conditions.
If present, signs of increased intraorbital pressure such as blurred vision, limited eye movement, protrusion of the eyeball, and swelling or blistering of the conjunctiva (the covering of the white of the eye) point to the more serious condition of orbital cellulitis.
The majority of periorbital infections are caused by common staph and strep bacteria. The pediatric hospitalists find that IV and oral antibiotics are equally effective in the treatment of most cases of simple periorbital cellulitis.
The choice of IV over oral antibiotics is a clinical decision based on the overall appearance of the young patient, as well as on his/her ability to take oral medication, the likelihood of family compliance with the proposed antibiotic therapy, and the clinical progression of each individual case of pediatric periorbital infection.
Hauser and Fogarasi add that, once on appropriate antibiotics, signs and symptoms of periorbital cellulitis should improve even within the first 24 to 48 hours of treatment.
• Dr. Helen Minciotti is a mother of five and a pediatrician with a practice in Schaumburg. She formerly chaired the Department of Pediatrics at Northwest Community Hospital in Arlington Heights