Orbital vs Preseptal Cellulitis: Chandler Classification and Management

Last updated: October 2026

Preseptal and orbital cellulitis look alike at first, but orbital cellulitis can blind or kill. The examination findings that separate them, when to scan, and when to operate.

Preseptal or orbital?

Chandler classification

1. I: preseptal cellulitis
2. II: orbital cellulitis
3. III: subperiosteal abscess
4. IV: orbital abscess
5. V: cavernous sinus thrombosis

Causes and organisms

• Most often spread from ethmoid sinusitis through the thin lamina papyracea; also dental infection, dacryocystitis, trauma and surgery.
• Streptococci, Staphylococcus aureus (including MRSA), Haemophilus influenzae (less since vaccination) and anaerobes.
• Mucormycosis in uncontrolled diabetes, ketoacidosis or immunosuppression (seen widely in India after COVID-19): black necrotic eschar, orbital apex syndrome, needs urgent debridement and amphotericin B.

Investigations

• Contrast CT of orbits and sinuses if there is proptosis, restricted movement, reduced vision, inability to examine, no improvement in 24–48 hours, or suspected abscess.
• Blood count, blood cultures, and swabs of any discharge; MRI if cavernous sinus thrombosis or intracranial spread is suspected.

Management

• Preseptal: oral amoxicillin–clavulanate with review in 24–48 hours; admit young children who are unwell.
• Orbital: admit; IV antibiotics (for example ceftriaxone plus metronidazole, adding vancomycin where MRSA is likely); nasal decongestants; ENT input. Check vision, colour and pupils every few hours.
• Surgery (drainage of abscess and sinuses) for falling vision or RAPD, a large or non-medial abscess, no improvement after 24–48 hours of IV antibiotics, or an abscess in an older child or adult. Small medial subperiosteal abscesses in children under about 9 years often settle with antibiotics alone.

Related: emergencies on call, infection regimens, oculoplasty.

Key sources

• Chandler JR, Langenbrunner DJ, Stevens ER. The pathogenesis of orbital complications in acute sinusitis. Laryngoscope 1970;80:1414–28
• Garcia GH, Harris GJ. Criteria for nonsurgical management of subperiosteal abscess of the orbit. Ophthalmology 2000;107:1454–8
• American Academy of Ophthalmology. BCSC Section 7: Oculofacial Plastic and Orbital Surgery (current edition)