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Cellulitis, Preseptal
Article Last Updated: Apr 4, 2008
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: Aaron L Sobol, MD, Medical Director, Laurel Ridge Eyecare, Tulane University School of Medicine
Aaron L Sobol is a member of the following medical societies: American Academy of Ophthalmology and American Society of Cataract and Refractive Surgery
Coauthor(s):
Kelly A Hutcheson, MD, Associate Professor, Department of Ophthalmology, George Washington University School of Medicine, Children's National Medical Center,
Editors: Brian A Phillpotts, MD, Former Vitreo-Retinal Service Director, Former Program Director, Clinical Assistant Professor, Department of Ophthalmology, Howard University College of Medicine; Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles; Mark T Duffy, MD, PhD, Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal, and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic; Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri; Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Author and Editor Disclosure
Synonyms and related keywords:
preseptal cellulitis, periorbital cellulitis, eyelid infection, eyelid erythema, eyelid edema, bacterial infection, upper respiratory tract infection, ocular infection, eyelid trauma, orbital cellulitis, postseptal cellulitis, orbital septum
Background
Preseptal cellulitis is a common infection of the eyelid and periorbital soft tissues characterized by acute eyelid erythema and edema. This bacterial infection usually results from local spread of adjacent upper respiratory tract infection, external ocular infection, or following trauma to the eyelids. Preseptal cellulitis tends to be a less severe disease than orbital cellulitis (postseptal cellulitis), which can present in a similar manner. 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.
Pathophysiology
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. 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. 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. 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 has come into widespread use, the rate of Haemophilus-positive blood cultures has dropped; studies report 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 the era of concern about biologic warfare, it is also important to note that periorbital cellulitis has also been reported with both smallpox and anthrax.
Frequency
United States
In 1995, approximately 5000 US inpatients had an International Classification of Diseases, 9th revision (ICD-9), diagnosis of deep inflammation of the eyelid as a primary discharge diagnosis according to the National Center for Disease Statistics.
Mortality/Morbidity
- Morbidity occurs from the spread of pathogens to the orbit, which can threaten vision and result in 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.
- Earlier diagnosis, expeditious treatment, and improved antibiotics have led to a reduction of serious ocular and CNS complications.
Race
No known racial predilection exists.
Sex
No known sexual predilection exists.
Age
Preseptal cellulitis is primarily a pediatric disease with approximately 80% of patients younger than 10 years and most patients younger than 5 years. Patients with preseptal cellulitis tend to be younger than patients with orbital cellulitis.
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, it is widely believed that these responses cannot be used to differentiate between the 2 conditions.
- Patients may complain of the following:
- Pain
- Conjunctivitis
- Epiphora
- Blurred vision
- Signs include periorbital erythema and edema (sometimes so severe that patients cannot voluntarily open the eye).
Physical
Because both orbital cellulitis and preseptal cellulitis can 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 both vision and pupillary reactions in all patients presenting with eyelid inflammation, as evidence of limited motility or impaired vision suggests that 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 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.
Causes
- Antecedent events may include the following recent eyelid lesions:
- Hordeola
- Chalazia
- Bug bites
- Trauma
- Recent surgical procedures near the eyelids
- Oral procedures
- A concurrent or recent upper respiratory tract infection, especially sinusitis, may be present.
- Many systemic diseases have been reported with concurrent preseptal cellulitis.
- Varicella
- Asthma
- Nasal polyposis
- Neutropenia
Cellulitis, Orbital
Conjunctivitis, Bacterial
Conjunctivitis, Viral
Dacryoadenitis
Dacryocystitis
Dermatitis, Contact
Herpes Simplex
Herpes Zoster
Hordeolum
Red Eye Evaluation
Other Problems to be Considered
Rhabdomyosarcoma
Retinoblastoma
Orbital pseudotumor (idiopathic orbital inflammation)
Lab Studies
- 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.
- 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 between preseptal cellulitis and orbital cellulitis.
- Samples of conjunctival discharge, eyelid lesions, and lacrimal sac material should be sent for culture.
Imaging Studies
- 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, and resistance on retropulsion.
- 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 neurological symptoms or neurological 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
- A CT scan can delineate the extent of orbital involvement. 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
- Orbital ultrasound 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.
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.
Medical Care
Treatment involves management of predisposing conditions, antibiotic therapy, and close observation. - 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.
- In older children or adults with mild preseptal cellulitis, outpatient treatment may be considered with amoxicillin/clavulanic acid or a first-generation cephalosporin. Outpatient management with intramuscular ceftriaxone also is possible. If the patient fails to respond within 48-72 hours, consider intravenous antibiotics.
- In younger children or in more severe cases, admission for close observation and intravenous antibiotics are standard. Many published regimens exist for empiric therapy, but no regimen has been tested in clinical trials. A second- or third-generation cephalosporin (eg, cefuroxime, ceftriaxone) provides adequate coverage, even with resistant S pneumoniae. If anaerobes or S aureus are suspected, then clindamycin with a cephalosporin provides coverage. Other primary antibiotics include penicillinase-resistant synthetic penicillins (eg, nafcillin, oxacillin), especially if S aureus is suspected.
- Clinical improvement should be seen within 24-48 hours. If the patient worsens, then consider an underlying orbital process or resistant organisms.
- After clinical improvement on 48-72 hours of intravenous antibiotics is demonstrated, a trial of oral antibiotics for 24 hours can be tried. If the clinical improvement continues, the patient can be observed on an outpatient basis. Oral antibiotics should be continued for 10 days. Such conservative treatment strategies are recommended, particularly for pediatric patients.
Surgical Care
Surgical drainage is indicated only for eyelid abscesses and usually is not needed for uncomplicated preseptal cellulitis.
Consultations
- Consultation should be considered in cases where the eye cannot be evaluated or if orbital spread is suspected. Ophthalmic consultation and evaluation is recommended for all pediatric patients.
- Otorhinolaryngology consultation is suggested for medical and surgical treatment of sinusitis.
The goal of pharmacotherapy is to reduce morbidity and to prevent complications. Drugs described below are antibiotics commonly used to treat preseptal cellulitis.
Drug Category: Antibiotics
Antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
| Drug Name | Amoxicillin and clavulanate (Augmentin) |
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| Description | Third-generation aminopenicillin. Combined with the beta-lactam, clavulanic acid, is less susceptible to degradation by beta-lactamases produced by microorganisms. |
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| Adult Dose | 250-500 mg PO tid |
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| Pediatric Dose | <3 months: 30 mg/kg PO divided q12h
>3 months: 45 mg/kg PO divided q12h or 40 mg/kg divided tid |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Probenecid can decrease renal excretion of amoxicillin, but not clavulanic acid; pregnant women may have a transient decrease in plasma concentration of total conjugated estriol, estriol-glucuronide, conjugated estrone, and estradiol |
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| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
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| Precautions | Pseudomembranous colitis is associated with amoxicillin; Augmentin is associated with cholestatic jaundice and hepatic dysfunction; high urine concentrations of ampicillin may result in false-positive reactions when testing for presence of glucose in urine using commercial tests |
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| Drug Name | Ceftriaxone (Rocephin) |
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| Description | Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins. |
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| Adult Dose | 1-2 g IV/IM qd or divided q12h |
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| Pediatric Dose | 50-75 mg/kg IV/IM qd or divided q12h; not to exceed 2 g |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Alterations in prothrombin times have occurred rarely in patients treated with ceftriaxone; patients with impaired vitamin K synthesis or low vitamin K stores may require monitoring of prothrombin time during ceftriaxone treatment; vitamin K (10 mg/wk) may be necessary if prothrombin time is prolonged before or during therapy; probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity |
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| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
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| Precautions | Nephrotoxic potential of ceftriaxone is similar to that of other cephalosporins; caution in history of gastrointestinal disease, especially colitis |
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| Drug Name | Clindamycin (Cleocin) |
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| Description | Semisynthetic antibiotic produced by a 7(S)-chloro-substitution of the 7(R)-hydroxyl group of the parent compound lincomycin. |
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| Adult Dose | 150-300 mg PO q6h |
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| Pediatric Dose | 8-16 mg/kg/d PO divided tid/qid |
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| Contraindications | Documented hypersensitivity; regional enteritis, ulcerative colitis, hepatic impairment, antibiotic-associated colitis |
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| Interactions | Increases duration of neuromuscular blockade, induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin |
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| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
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| Precautions | Caution in history of gastrointestinal disease, particularly colitis; elderly persons may not tolerate colitis as well as younger individuals; caution in atopic individuals; hepatic and renal function should be monitored with chronic use |
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| Drug Name | Nafcillin (Unipen) |
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| Description | For suspected penicillin G-resistant streptococcal or staphylococcal infections. Second-generation penicillinase penicillin.
Use parenteral therapy initially in severe infections. Change to oral therapy as condition warrants.
Due to thrombophlebitis, particularly in elderly persons, administer parenterally only for short term (1-2 d); change to oral route as clinically indicated. |
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| Adult Dose | 0.5-1 g IV q4h |
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| Pediatric Dose | 0-4 kg (neonates): 10 mg/kg IM bid
4-40 kg: 25 mg/kg IM bid
Alternatively, 100-200 mg/kg/d IV/IM in 4-6 divided doses
PO dosing for children: 50 mg/kg/d PO divided qid |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Associated with warfarin resistance when administered concurrently; effects may decrease with bacteriostatic action of tetracycline derivatives; when used with cyclosporine, subtherapeutic levels of cyclosporine are possible |
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| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
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| Precautions | To optimize therapy, determine causative organisms and susceptibility; >10 d treatment to eliminate infection and prevent sequelae (eg, endocarditis, rheumatic fever); take cultures after treatment to confirm that infection is eradicated; oral route of administration should not be relied upon in patients with severe illness, or with nausea, vomiting, gastric dilatation, cardiospasm, or intestinal hypermotility |
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| Drug Name | Cephalexin (Keflex, Biocef) |
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| Description | First-generation cephalosporin arrests bacterial growth by inhibiting bacterial cell wall synthesis. Bactericidal activity against rapidly growing organisms. Primary activity against skin flora; used for skin infections or prophylaxis in minor procedures. |
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| Adult Dose | 1-4 g PO qd in divided doses; usual adult dose is 250 mg PO q6h; if qd doses of cephalexin >4 g required, parenteral cephalosporins, in appropriate doses, should be considered |
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| Pediatric Dose | 25-50 mg/kg PO in divided doses |
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| Contraindications | Documented hypersensitivity |
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| Interactions | False-positive reaction for glucose in urine may occur; coadministration with aminoglycosides increase nephrotoxic potential |
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| Pregnancy | C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
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| Precautions | Prolonged use may result in overgrowth of nonsusceptible organisms; caution in presence of markedly impaired renal function |
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Further Inpatient Care
- If the patient responds to empiric antibiotics and can be switched to oral antibiotics, further care can be provided on an outpatient basis.
Further Outpatient Care
- 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.
In/Out Patient Meds
- 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
Transfer
- Transfer may be required if otorhinological or ophthalmological specialties are not available.
Deterrence/Prevention
- Topical antibiotics may prevent traumatic lid lacerations from becoming infected and causing cellulitis.
- Adequate treatment of bacterial sinusitis may prevent spread to adjacent tissues.
Complications
- Infection may spread along tissue planes to cause subperiosteal abscess, orbital abscess, and cavernous sinus thrombosis.
- In a study of pediatric patients with intracranial infection, high-risk features included the following: age older than 7 years, subperiosteal abscess, and headache and fever persisting despite IV antibiotics.
- Patients who are immunocompromised 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 having a low index of suspicion, is indicated for these patients.
Prognosis
- If identified and treated promptly, the prognosis for complete recovery without complication is excellent.
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.
- For excellent patient education resources, see eMedicine's Diabetes Center. Also, visit eMedicine's patient education article, Cellulitis.
Medical/Legal Pitfalls
- Failure to diagnose orbital spread of an eyelid infection is the most common pitfall.
| Media file 1:
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. |
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| Media file 2:
Preseptal cellulitis. This image shows an 8-year-old patient who presented with unilateral eyelid swelling and erythema. |
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Media type: Photo
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Cellulitis, Preseptal excerpt Article Last Updated: Apr 4, 2008
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