Lid/Orbit
Orbital Cellulitis
Also known as: orbital cellulitis, postseptal cellulitis, orbital infection, post-septal orbital infection, subperiosteal abscess orbit, proptosis infection, restricted eye movement infection, sinusitis orbit complication
Filed as: Emergency
Source-cited from the record's own evidence list. Clinical content programme led by Dr Ankit Mathur, PhD, Grad Cert Ocu Thera, B.S. Optom. How the clinical content is governed
Clinical decision support only
Overview
Infection posterior to the orbital septum involving orbital tissues such as extraocular muscles, orbital fat, and optic nerve/blood supply structures. A sight-threatening and life-threatening emergency, most often from bacterial sinusitis. Distinguished from preseptal cellulitis by orbital signs such as pain with eye movement, restricted motility, diplopia, proptosis, reduced vision, RAPD, or chemosis.
Recognition
Symptoms: what patients report
- Periorbital and eyelid swelling and redness.
- Conjunctival injection or chemosis.
- Proptosis — forward displacement of the globe.
- Painful or restricted eye movement — diplopia.
- Reduced visual acuity.
- Fever, malaise, and systemic illness.
- Headache.
- Preceding sinusitis, URTI, dental/ear infection, dacryocystitis, recent ophthalmic procedure, immunodeficiency, or facial/orbital trauma.
- Pain on pressure over the orbit.
Signs: what the examination shows
- Proptosis (exophthalmos) — globe displaced anteriorly.
- Ophthalmoplegia or restricted, painful eye movements in all directions.
- Periorbital oedema and erythema.
- Conjunctival chemosis and injection.
- Reduced visual acuity or colour vision — indicates optic nerve compromise.
- Relative afferent pupillary defect (RAPD) — indicates optic nerve involvement, emergency.
- Elevated IOP.
- Swinging light test — check for RAPD at every visit.
- Subperiosteal or orbital abscess: non-axial proptosis with the globe displaced away from the abscess (typically inferolaterally, because most arise medially or superomedially from the ethmoid or frontal sinus); marked resistance to retropulsion.
- Possible vascular occlusion or optic neuropathy when orbital pressure compromises blood supply.
What OptoGuide™ covers for orbital cellulitis
- Pattern reasoning: what this combination of findings points to, and its differentiators
- Don't-miss risks and escalation triggers
- Management tiers with linked New Zealand therapeutics
- Referral urgency, specialty, and letter drafting
Sources
- Cellulitis, preseptal and orbital — College of Optometrists CMG
- Orbital Cellulitis — EyeWiki
- Acute Bilateral Blindness in the Setting of Sudden Onset of Bilateral Proptosis and Ophthalmoplegia: A Case Report With Literature Review. Zarei S, Vo P, Sam C, et al. Neurology. Clinical Practice. 2021;11(5):e706-e713.
- High Risk and Low Prevalence Diseases: Orbital Cellulitis. Pelletier J, Koyfman A, Long B. The American Journal of Emergency Medicine. 2023;68:1-9.
- Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2024 Update by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM). Miller JM, Binni
- Rhinosinusitis: Evidence and experience - 2024. Romano FR, Anselmo-Lima WT, Kosugi EM, et al. Brazilian Journal of Otorhinolaryngology. 2025;91(5):101595.
- Anticoagulation for cavernous sinus thrombosis: a systematic review and individual patient data meta-analysis. Akarapas C, Wiwatkunupakarn N, Sithirungson S, Chaiyasate S. Eur Arch Otorhinolaryngol. 2025;282(3):1127-1134.
- Preseptal versus orbital cellulitis in children: an observational study. Miranda-Barrios J, Bravo-Queipo-de-Llano B, Baquero-Artigao F, et al. Pediatr Infect Dis J. 2021;40(11):969-974.
- Orbital rhabdomyosarcoma: a case series. Kaliaperumal S, Tiroumal S, Rao VA. Indian J Cancer. 2007;44(3):104-7.
- Global guideline for the diagnosis and management of mucormycosis: an initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research Consortium. Cornely OA, Alastruey-Izquierdo A, Arenz D, et al. Lancet Infect Dis. 2019;19(12):e405-e421.
Standard texts: Kanski's Clinical Ophthalmology: A Systematic Approach, The Wills Eye Manual, Oxford Handbook of Ophthalmology, Oxford American Handbook of Ophthalmology, Signs in Ophthalmology: Causes & Differential Diagnosis.