By Stephanie Smith M.D.

HPI

• 53 y/o male p/w complaints of L eyelid swelling and redness
• Started 4 days PTA as small pimple which he popped, and slowly progressed to “softball” sized area of swelling with pus drainage
• Subjective fevers

Physical Exam

• BP 153/90, pulse 80, temp 98.6, RR 17
• PERRL, EOMI
• Extensive soft tissue erythema and edema of the L upper eyelid, 5×5 area of fluctuance with active pus draining from small laceration
• Visual acuity: 20/40 R, 20/70 L
• No corneal abrasions or ulceration on fluorescein staining 
• IOP 21 bilaterally 

DDx

• Preseptal / periorbital cellulitis
• Orbital cellulitis
• Abscess

Workup 

• Labs: CBC, BMP, lactate, wound culture
• Started empirically on broad spectrum abx: 2g vancomycin + 3g unasyn
• CT orbits w/ contrast: significant soft tissue swelling of the L periorbital region consistent with inflammatory/infectious process, and involvement of the medial orbital wall along the lamina papyracea 

Clinical Course

• Admission for continued IV antibiotics
• Repeat CT orbits
• Consults: OMFS, ophthalmology, ENT, ID 

Take home points

• MUST differentiate orbital vs preseptal cellulitis given the increased morbidity and mortality a/w orbital (see table)
• Confirm clinical suspicion with CT imaging
• Orbital cellulitis complications: subperiosteal abscess, orbital abscess, vision loss, cavernous sinus thrombophlebitis, and/or brain abscess