Preseptal Cellulitis


Preseptal Cellulitis, Periorbital Cellulitis

  • Pathophysiology
  1. Preseptal Cellulitis is a Eyelid soft tissue infection
  2. Thin fibrous, septal membrane extends from orbital rim to lid margin
    1. Forms a periosteal extension or septum that prevents extension or lid disease to orbit
  3. Preseptal Cellulitis infections form anterior to the fibrous septum
    1. Contrast with Orbital Cellulitis which involves the deeper tissues (esp. ethmoid or Maxillary Sinusitis)
  • Epidemiology
  1. Typical onset at age 18 months to 3 years
  • Causes
  1. Local Eyelid disease
    1. Hordeolum
    2. Chalazion
  2. Eyelid Trauma (e.g. Insect Bite) with secondary infection (e.g. Impetigo)
  3. Dental abscess or infection with local spread
  4. Sinusitis with local extension
    1. Uncommon in Preseptal Cellulitis
    2. Sinusitis is usually precursor to Orbital Cellulitis
  • Symptoms
  1. Acute Swollen Red Eyelid
  2. No fever
  3. No orbital pain or Extraocular Movement pain
    1. Contrast with painful Extraocular Movements in Orbital Cellulitis
  • Signs
  1. Periorbital rash
    1. Pink, violaceous swelling of lid margins
  2. Multiple features differentiate Periorbital Cellulitis from the worrisome Orbital Cellulitis
    1. No Extraocular Movement pain or weakness (Ophthalmoplegia)
    2. No Proptosis
    3. Normal Vision
    4. Normal pupil reflexes
    5. No Conjunctival injection (Conjunctivitis)
    6. No cells and flare (Iritis)
    7. No limitation or pain on eye movement
    8. No Chemosis
    9. No retrobulbar globe pressure
    10. No Papilledema
  • Differential Diagnosis
  1. See Eyelid Inflammation
  2. Orbital Cellulitis
    1. Inflames or entraps extraocular Muscles with painful or reduced Extraocular Movement
    2. May be associated with Diplopia and disconjugate gaze
  • Management
  1. Admit all cases of Orbital Cellulitis
    1. Typical Preseptal Cellulitis may be treated outpatient with oral antibiotics and close interval follow-up
  2. Close observation to rule out Orbital Cellulitis
    1. Hospitalize and treat Parenterally with broad spectrum antibiotics if evidence of bacteremia or toxicity
    2. See Orbital Cellulitis
    3. Lumbar Puncture if suspect bacteremia source
  3. Antibiotic Course: 10 days
  4. Two antibiotic regimen is recommended
    1. Sanford recommends second agent for added MRSA coverage
    2. Antibiotic 1 (choose one): Primary Preseptal Cellulitis coverage
      1. Amoxicillin-Clavulanate (Augmentin)
      2. Cefpodoxime (Vantin)
      3. Cefuroxime (Ceftin)
      4. Cefprozil (Cefzil)
      5. Cefdinir (Omnicef)
    3. Antibiotic 2 (choose one): MRSA Coverage
      1. Trimethoprim Sulfamethoxazole (Septra, Bactrim)
      2. Doxycycline
      3. Clindamycin
  • Complications
  1. Orbital Cellulitis (from contigious extension)
    1. Uncommon (<10% of Orbital Cellulitis extends from Preseptal Cellulitis)
    2. Most Orbital Cellulitis is an extension from ethmoid or Maxillary Sinusitis
  2. Intracerebral extension of Preseptal Cellulitis is rare without Orbital Cellulitis extension
    1. Protective fibrous layer prevents extension
  • References
  1. (2023) Sanford Guide, accessed 7/1/2023
  2. Williams (2017) Crit Dec Emerg Med 31(2): 3-12
  3. Broder (2023) Crit Dec Emerg Med 37(11): 20-2
  4. Givner (2002) Pediatr Infect Dis 21:1157-8 [PubMed]