Preseptal Cellulitis

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Background

Preseptal cellulitis is a common infection of the eyelid and periorbital soft tissues that is characterized by acute eyelid erythema and edema. This bacterial infection usually results from local spread of an adjacent sinusitis or dacryocystitis, from an external ocular infection, or following trauma to the eyelids (see the image below). (See E tiology and Presentation.)


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Preseptal cellulitis. This image shows an 8-year-old patient who presented with unilateral eyelid swelling and erythema.

Preseptal cellulitis tends to be a less severe disease than orbital cellulitis (postseptal cellulitis), which can present in a similar manner. Preseptal cellulitis differs from orbital cellulitis in that it is confined to the soft tissues that are anterior to the orbital septum. Preseptal cellulitis may spread posterior to the septum and progress to form subperiosteal and orbital abscesses. Infection in the orbit can spread posteriorly and cause cavernous sinus thrombosis or meningitis. (See Prognosis, Presentation, and Workup.)

Orbital cellulitis has a higher morbidity, requires aggressive treatment, and may require surgical intervention, whereas preseptal cellulitis usually is managed medically. Delineation of the exact location of inflammation is necessary for proper diagnosis and treatment. (See Prognosis and Treatment.) Pain or limited eye movement, chemosis, afferent pupil, or resistance to retropultion indicates orbital extention of the infection.

Orbital septum

Periorbital inflammation is classified by location and severity. One of the major anatomical landmarks in determining the location of disease is the orbital septum. The orbital septum is a thin membrane that originates from the orbital periosteum and inserts into the anterior surfaces of the tarsal plates of the eyelids. The septum separates the superficial eyelid from the deeper orbital structures, and it forms a barrier that prevents infection in the eyelid from extending into the orbit.

Patient education

Patients should be instructed that loss of vision or pain with eye movements is an indication that the infection has spread to the orbit and may necessitate surgical intervention. Increased edema and redness or pain in general are also warning signs.

For patient education information, see the Diabetes Center, as well as Cellulitis.

Etiology

Upper respiratory tract infections, especially paranasal sinusitis, commonly precede preseptal cellulitis. In 2 large case series, nearly two thirds of cases of cellulitis were associated with upper respiratory tract infection. One half of these cases were from sinusitis.

The most common organisms are Staphylococcus aureus, Staphylococcus epidermidis,Streptococcus species, and anaerobes, reflecting the organisms that commonly cause upper respiratory tract infections and external eyelid infections. Blood and skin culture results tend to be negative.

Prior to the introduction of the Haemophilus influenzae type b (Hib) polysaccharide vaccine, in 1985, H influenzae was the most common organism isolated in blood cultures.[1, 2, 3, 4] One study prior to the introduction of the vaccine noted that blood culture results were more likely to be positive (42%) if the patient had an upper respiratory infection and that subcutaneous aspirates were more likely to be positive (44%) if the patient had eyelid trauma or external ocular infection.

Since the vaccine came into widespread use, the rate of Haemophilus -positive blood cultures has dropped; studies have reported that the rate of any positive blood culture is now less than 4%. The reason that the rates for bacteremia for all organisms have dropped is unclear.

A study specifically looking at periorbital and orbital cellulitis since the advent of the vaccine likewise found that the rates of Hib-related cellulitis dropped, from 11.7% to 3.5%. Total cases per year from all pathogens also declined, suggesting that H influenzae may have played a facilitative role in the pathogenesis of cellulitis.

In an era of concern about biologic warfare, it is also important to note that periorbital cellulitis has also been reported with smallpox and anthrax.[5, 6, 7]

Risk factors

Antecedent events in preseptal cellulitis may include the following recent eyelid lesions:

An upper respiratory tract infection, especially sinusitis,[8] may be present concurrently with preseptal cellulitis or may have recently occurred. Many systemic diseases have been reported with concurrent preseptal cellulitis, including the following:

Epidemiology

According to the National Center for Disease Statistics, in 1995, approximately 5000 inpatients in the United States had a primary discharge diagnosis of deep inflammation of the eyelid, as specified in the International Classification of Diseases, 9th revision (ICD-9).

Preseptal cellulitis is primarily a pediatric disease, with approximately 80% of patients being younger than 10 years and most patients being younger than 5 years. Patients with preseptal cellulitis tend to be younger than patients with orbital cellulitis.

Prognosis

If preseptal cellulitis is identified and treated promptly, the prognosis for complete recovery without complication is excellent.

Morbidity occurs from the spread of pathogens to the orbit, which can threaten vision and result in central nervous system (CNS) spread. Untreated orbital cellulitis can lead to the development of an orbital abscess or can spread posteriorly to cause cavernous sinus thrombosis. Systemic spread of bacteria may lead to meningitis and sepsis.

In a study of pediatric patients with intracranial infection, high-risk features included the following[11] :

Patients who are immunocompromised or diabetic have a higher likelihood of developing fungal infections, which can rapidly become fatal. Aggressive management, including imaging studies of the brain and early IV therapy, along with a high index of suspicion, is indicated for these patients. Otolaryngologist consultation also should be ordered if fungal infection is suspected.

History

Patients may have mild to moderate temperature elevation. Although it has been suggested that orbital cellulitis generates a greater leukocytosis and febrile response than preseptal cellulitis does, it is widely believed that these responses cannot be used to differentiate the 2 conditions from each other.

Patients may complain of the following:

Signs of preseptal cellulitis include periorbital erythema and edema (sometimes so severe that patients cannot voluntarily open the eye).

Physical Examination

Because orbital cellulitis and preseptal cellulitis can each present with eyelid inflammation, it is important to perform a complete ocular examination. Be alert for signs of systemic illness, especially in children.

The eyelids and ocular adnexa should be inspected for signs of local trauma. Cervical, submandibular, or preauricular lymphadenopathy may be present. A tender preauricular lymph node may be suggestive of adenoviral conjunctivitis. Conjunctivitis may be present, and the quality of conjunctival drainage should be noted.

Test vision and pupillary reactions in all patients who present with eyelid inflammation, as evidence of limited motility or impaired vision suggests that the inflammation has spread to the orbit. An afferent pupillary defect suggests optic nerve compression, and immediate surgical drainage should be performed.

Resistance to retropulsion and proptosis suggest orbital involvement. An eyelid speculum may be needed to examine the eye and ocular movements.

The ocular fundus should be examined carefully for signs of optic nerve swelling and venous engorgement.

Inspect for possible dacryocystitis[9] or dacryoadenitis, which can result in the spread of inflammation to adjacent tissues.

Sinus tenderness, rhinorrhea, adenopathy, and other hallmarks of upper respiratory tract infection may be present.[9]

Approach Considerations

Blood culture results are positive in less than 10% of cases of preseptal cellulitis. Prior to the introduction of the Hib vaccine, blood cultures were positive in up to one third of patients. Blood cultures are rarely necessary in preseptal and even orbital cellulitis, unless sepsis is suspected.

White blood cell (WBC) counts tend to be elevated. One study demonstrated an average WBC count of 14,700 cells/µL in patients without bacteremia and 20,400 cells/µL in patients with bacteremia. It is generally believed that the WBC count cannot be used to differentiate preseptal cellulitis from orbital cellulitis.

Samples of conjunctival discharge, eyelid lesions, and lacrimal sac material should be sent for culture.

Imaging

Findings on examination that warrant imaging studies include pain on eye movement, afferent pupillary defect, limited extraocular motions, and resistance on retropulsion.

A computed tomography (CT) scan can delineate the extent of orbital involvement but is not necessary in all patients with preseptal cellulitis.[16] Orbital ultrasonography can be a useful tool to help in diagnosing orbital inflammation, although it requires experienced observers and specialized equipment that may not be available at most institutions. Orbital ultrasound very rarely, if ever, needed.

Procedures

Consider lumbar puncture in all neonates and in patients with signs or symptoms of meningitis. Eyelid abscesses should be incised and drained if present.

Histologic findings

Biopsy shows edema and polymorphonuclear leukocytes infiltrating tissue planes.

CT Scanning

A CT scan of the orbit is not necessary for all cases of preseptal cellulitis. For older patients who clearly have limited infection, conservative management is appropriate. When it is unclear whether deeper orbital structures are involved (eg, limited ocular motility), a CT scan is indicated. Consider a CT scan for all children in whom age makes a reliable examination difficult.

Findings on examination that warrant imaging studies include pain on eye movement, afferent pupillary defect, limited extraocular motions, resistance on retropulsion, and arteriolization of conjunctival blood vessels.

An appropriate CT scan would include thin axial sections through the orbits and sinuses and either true coronal sections or coronal reconstructions. A CT scan of the head is also indicated for any neurologic symptoms or neurologic findings on examination.

CT scan findings in preseptal cellulitis include the following:

Staging[17]

A CT scan can delineate the extent of orbital involvement.[16] The modified Chandler staging system describes a spectrum of disease, as follows:

Approach Considerations

Earlier diagnosis, expeditious treatment, and improved antibiotics have led to a reduction of serious ocular and CNS complications in patients with preseptal cellulitis. Treatment involves management of predisposing conditions, antibiotic therapy, and close observation.[18]

Initial antibiotic therapy is empiric, and, in most cases, a pathogen will not be identified. Given the predisposing factors, antibiotic choice should be directed toward the organisms that cause upper respiratory infections, particularly sinusitis. Specific organisms include Streptococcus pneumoniae, nontypeable H influenzae, and Moraxella catarrhalis. In cases due to focal trauma, treatment should include coverage for S aureus.

Drainage

Surgical drainage is indicated only for eyelid abscesses[9] and usually is not needed for uncomplicated preseptal cellulitis. Drainage is also indicated in acute dacryocystitis.

Consultations

Consultation should be considered in cases in which the eye cannot be evaluated or if orbital spread is suspected. Ophthalmic consultation and evaluation is recommended for all pediatric patients.[19] Otorhinolaryngology consultation is suggested for medical and surgical treatment of sinusitis and if fungal infection is suspected. Infectious disease consultation is needed in all cases not responding to conservative management.

Outpatient care

If an inpatient responds to empiric antibiotics and can be switched to oral antibiotics, further care can be provided on an outpatient basis.

On outpatient follow-up care, the patient should be evaluated for signs of relapse, including fever, erythema, edema, pain, and vision loss. If a history of chronic sinusitis is present, otolaryngology follow-up care should be arranged.

Deterrence

The following treatments can discourage the development of preseptal cellulitis:

Transfer

Transfer may be required if otorhinologic or ophthalmologic specialties are not available.

Medication Summary

Medications used in the treatment of preseptal cellulitis include the following:

For patients on IV antibiotics, clinical improvement after 48-72 hours of IV administration means that a 24-hour trial of oral antibiotics can be employed.

Amoxicillin and clavulanate (Augmentin, Amoclan, Augmentin XR)

Clinical Context:  Amoxicillin is a third-generation aminopenicillin. Combined with the beta-lactam clavulanic acid, it is less susceptible to degradation by beta-lactamases produced by microorganisms.

Ceftriaxone (Rocephin)

Clinical Context:  Ceftriaxone is a third-generation cephalosporin with broad-spectrum, gram-negative activity. It has lower efficacy against gram-positive organisms and higher efficacy against resistant organisms. Ceftriaxone arrests bacterial growth by binding to 1 or more penicillin-binding proteins.

Clindamycin (Cleocin)

Clinical Context:  Clindamycin is a semisynthetic antibiotic produced by a 7(S)-chloro-substitution of the 7(R)-hydroxyl group of the parent compound lincomycin.

Nafcillin

Clinical Context:  Nafcillin, a second-generation penicillinase penicillin, is used for suspected penicillin G-resistant streptococcal or staphylococcal infections. In severe infections, it should initially be used parenterally, with a change to oral therapy as the condition warrants.

Due to thrombophlebitis, particularly in elderly persons, administer nafcillin parenterally for only a short term (1-2d); change to the oral route as clinically indicated.

Cephalexin (Keflex)

Clinical Context:  Cephalexin is a first-generation cephalosporin that arrests bacterial growth by inhibiting bacterial cell wall synthesis. It has bactericidal activity against rapidly growing organisms. Cephalexin's primary activity is against skin flora. Cephalexin is used for skin infections or prophylaxis in minor procedures.

Oxacillin

Clinical Context:  Oxacillin is a bactericidal antibiotic that inhibits cell wall synthesis. It is used in the treatment of infections caused by penicillinase-producing staphylococci. It may be used to initiate therapy when a staphylococcal infection is suspected.

Cefuroxime (Ceftin, Zinacef)

Clinical Context:  Cefuroxime is a second-generation oral cephalosporin antibiotic that inhibits cell wall synthesis and is bactericidal.

Class Summary

Antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Author

Geoffrey M Kwitko, MD, FACS, FICS, Clinical Associate Professor, Department of Ophthalmology, University of South Florida College of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Aaron L Sobol, MD, Medical Director, Laurel Ridge Eyecare, Tulane University School of Medicine

Disclosure: Nothing to disclose.

Kelly A Hutcheson, MD, MBA, Associate Professor, Department of Ophthalmology, George Washington University School of Medicine, Children's National Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Disclosure: Nothing to disclose.

Additional Contributors

Simon K Law, MD, PharmD Associate Professor of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Brian A Phillpotts, MD Former Vitreo-Retinal Service Director, Former Program Director, Clinical Assistant Professor, Department of Ophthalmology, Howard University College of Medicine

Brian A Phillpotts, MD is a member of the following medical societies: American Academy of Ophthalmology, American Diabetes Association, American Medical Association, and National Medical Association

Disclosure: Nothing to disclose.

References

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  2. Ambati BK, Ambati J, Azar N, Stratton L, Schmidt EV. Periorbital and orbital cellulitis before and after the advent of Haemophilus influenzae type B vaccination. Ophthalmology. Aug 2000;107(8):1450-3. [View Abstract]
  3. Barone SR, Aiuto LT. Periorbital and orbital cellulitis in the Haemophilus influenzae vaccine era. J Pediatr Ophthalmol Strabismus. Sep-Oct 1997;34(5):293-6. [View Abstract]
  4. Donahue SP, Schwartz G. Preseptal and orbital cellulitis in childhood. A changing microbiologic spectrum. Ophthalmology. Oct 1998;105(10):1902-5; discussion 1905-6. [View Abstract]
  5. Artac H, Silahli M, Keles S, Ozdemir M, Reisli I. A rare cause of preseptal cellulitis: anthrax. Pediatr Dermatol. May-Jun 2007;24(3):330-1. [View Abstract]
  6. Hu G, Wang MJ, Miller MJ, Holland GN, Bruckner DA, Civen R, et al. Ocular vaccinia following exposure to a smallpox vaccinee. Am J Ophthalmol. Mar 2004;137(3):554-6. [View Abstract]
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  13. Agarwal M, Biswas J, S K, Shanmugam MP. Retinoblastoma presenting as orbital cellulitis: report of four cases with a review of the literature. Orbit. Jun 2004;23(2):93-8. [View Abstract]
  14. Jacobs D, Galetta S. Diagnosis and management of orbital pseudotumor. Curr Opin Ophthalmol. Dec 2002;13(6):347-51. [View Abstract]
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Preseptal cellulitis. This image shows an 8-year-old patient who presented with unilateral eyelid swelling and erythema.

This image shows a 10-year-old child who presented with fever, acute unilateral eyelid erythema, and limited extraocular motions. The presentation is suspicious for orbital cellulitis.

Preseptal cellulitis. This image shows an 8-year-old patient who presented with unilateral eyelid swelling and erythema.