Preseptal Cellulitis

Background

Preseptal cellulitis is a common infection of the eyelid and periorbital soft tissues that is characterized by acute eyelid erythema and edema. Preseptal cellulitis may be caused by bacteria, viruses, fungi, or helminths. Bacterial infections may result 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 Etiology and Presentation.)

View Image

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 have a similar initial presentation. Preseptal cellulitis differs from orbital cellulitis in that it is confined to the soft tissues that are anterior to the orbital septum.

Preseptal and orbital cellulitis can be a continuum. Preseptal cellulitis can spread posterior to the septum, progressing 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 retropulsion indicates orbital extension 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.

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Etiology

Direct inoculation and spread from adjacent tissues can cause preseptal cellulitis. Upper respiratory tract infections, especially paranasal sinusitis, commonly precede orbital cellulitis and some cases of 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:

• Hordeola
• Chalazia
• Bug bites^[8]
• Trauma-related lesions^{[9, 8]}
• Lesions caused by a recent surgical procedure near the eyelids^[9]
• Lesions caused by oral procedures
• Dacryocystitis

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:

• Varicella
• Asthma
• Nasal polyposis
• Neutropenia^[10]

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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.

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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] :

• Age older than 7 years
• Subperiosteal abscess
• Headache^[12] and fever persisting despite the use of intravenous (IV) antibiotics

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.

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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:

• Pain
• Conjunctivitis
• Epiphora
• Blurred vision

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

Following periorbital trauma, foreign body should be excluded.

In febrile patients with pain disproportionate to clinical findings, periorbital necrotizing fasciitis should be considered.

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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. Limited motility, impaired vision, and/or relative afferent pupillary defects suggest that the inflammation has spread beyond the septum. A relative afferent pupillary defect indicates optic nerve compression, and immediate surgical drainage should be performed.

Resistance to retropulsion and proptosis also suggest orbital involvement. A Desmarres retractor or 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]

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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.

In patients with pain disproportionate to signs and suspected periorbital necrotizing fasciitis, the laboratory risk indicator for necrotizing fasciitis (LRINEC), particularly markedly elevated C-reactive protein levels, may be of some utility.^[16]

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.^[17] 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.

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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 imaging in all children with an advanced presentation or if a foreign body is suspected.

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

An appropriate CT scan would include thin axial sections through the orbits and sinuses and coronal views. 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:

• Swelling of the eyelid and adjacent preseptal soft tissues
• Obliteration of the fat planes or details of the preseptal soft tissues
• Absence of orbital inflammation

Staging ^[18]

A CT scan can delineate the extent of orbital involvement.^[17] The modified Chandler staging system describes a spectrum of disease, as follows:

• Stage I - Preseptal cellulitis
• Stage II - Inflammatory orbital edema
• Stage III - Subperiosteal abscess
• Stage IV - Orbital abscess
• Stage V - Cavernous sinus thrombosis

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Imaging Studies

Although MRI has no ionizing radiation, orbital MRI has a much longer acquisition time than CT scanning does. MRI may be difficult to perform in young children without sedation and difficult to obtain after hours. MRI with diffusion-weighted imaging may assist in the diagnosis of orbital abscess.^[19]

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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.^[20]

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. Methicillin-resistant S aureus (MRSA) should be excluded.^[21]

The extent of the cutaneous erythema can be outlined with a marking pen or photodocumented to determine progression or improvement on serial evaluation.

Drainage

Surgical drainage may be required for eyelid abscesses^[9] but is usually unnecessary for uncomplicated preseptal cellulitis. Drainage may also be indicated in acute, pointing 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.^[22] 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. Ambulatory intravenous therapy with daily review is a possible alternative to inpatient admission in patients with pediatric preseptal cellulitis.^[23]

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:

• Topical antibiotics may prevent traumatic lid lacerations from becoming infected and causing cellulitis
• Adequate treatment of bacterial sinusitis may prevent spread to adjacent tissues

Transfer

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

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Medication Summary

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

• Amoxicillin/clavulanic acid or intramuscular ceftriaxone - Considered for outpatient treatment in selected patients
• Second- or third-generation cephalosporins - Possible choice for initial empiric therapy
• Penicillinase-resistant synthetic penicillin (eg, nafcillin, oxacillin) - If S aureus is suspected

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.

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Amoxicillin and clavulanate (Augmentin, Amoclan, Augmentin XR)

• Dosing, Interactions, etc.

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.

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Ceftriaxone (Rocephin)

• Dosing, Interactions, etc.

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.

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Clindamycin (Cleocin, Cleocin Pediatric, ClindaMax Vaginal)

• Dosing, Interactions, etc.

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.

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Nafcillin

• Dosing, Interactions, etc.

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.

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Cephalexin (Keflex)

• Dosing, Interactions, etc.

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.

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Oxacillin

• Dosing, Interactions, etc.

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.

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Cefuroxime (Ceftin, Zinacef)

• Dosing, Interactions, etc.

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

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Class Summary

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

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