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spread of infection including visual disturbances, altered mental status, and
sepsis.
Clinical Assessment. The primary concern when making the diagnosis of
periorbital cellulitis is to rule out the possibility of orbital cellulitis. The cardinal
signs of orbital cellulitis include decreased or painful eye movement, proptosis,
changes in vision (e.g., change in acuity, decreased color vision, or visual field
deficits), and papilledema (or other signs of optic nerve involvement such as
Marcus Gunn pupil). Patients with orbital cellulitis may be irritable, toxic, and
have a fever, but the presence of fever and leukocytosis are not sensitive enough
markers to discriminate between the two conditions. Due to the presence of the
orbital septum which acts as a structural barrier, the eyelid swelling of orbital
cellulitis typically does not extend beyond the superior orbital rim onto the brow.
The ED clinician should be aware that acute periorbital edema and erythema
can also occur without infection. Insect bites and allergic reactions can cause
dramatic acute periorbital swelling, typically with minimal induration or
tenderness, and oftentimes with pruritus. These conditions are not usually
associated with fever. Often, close inspection of the skin with magnification can
localize a site of an insect bite. Swelling related to systemic allergic reactions is
often bilateral, whereas periorbital cellulitis is rarely bilateral. Underlying
sinusitis can also cause periorbital swelling without cellulitis. Conditions which
may mimic some of the physical findings of orbital cellulitis include orbital
tumors (e.g., rhabdomyosarcoma, neuroblastoma), orbital pseudotumor (an
immune-mediated process), leukemia, and sickle cell crisis. The best way to
differentiate these mimickers of orbital cellulitis is with CT or MRI of the orbits
and sinuses.