Preseptal Cellulitis

Prepared by: Junior Intern Charles Nicole P. Alonzo

Cellulitis

• is a skin infection (inflammation) characterized with redness., swelling, pain and warmth.

Preseptal type (or Periorbital)• also known as eyelid cellulitis, is a medical

condition that occurs around the eyelid

Preseptal cellulitis

• is a periocular superficial cellulitis that has not breached the orbital septum

Periorbital Cellulitis

Findings: Inflammation and swelling of soft tissues anterior to, but not posterior to the orbital septum, consistent with periorbital cellulitis.

Pathophysiology

• This may also arise in one of three situations:– As a result of local skin trauma such as lacerations

and insect bites– Due to spread from local infection such as

dacrocystitis, hordeolum and paranasal sinuses– Spread from distant infections such as those

outlined above as well as from the upper respiratory tract.

The most common pathogenic organisms are

– S. aureus, – S. epidermidis, – streptococci – anaerobes

• MRSA has also been isolated in cases but again, this currently remains very rare

Symptoms

• Unilateral

• Tenderness, erythema and swelling of lids and periorbital area

• May be a mild fever

• Often recent history of sinusitis/local skin abrasions or bites

Signs

• Erythema with tense edema: may not be able to open lid

• Tenderness

• Normal or just slightly blurred visual acuity

Signs

• Absence of– Proptosis

– Restriction in ocular motility

– Pain on eye movement

– Evidence of optic neuropathy

Differential Diagnosis Orbital/Preseptal Cellulitis

• Necrotising fasciitis• Chalazion• Allergic lid swelling• Severe viral conjunctivitis• Cavernous sinus thrombosis• Erysipelas• Other orbital conditions e.g. thyroid eye disease, orbital

tumours/pseudotumours, orbital vasculitis• Other conditions e.g. insect bite, angioedema,

maxillary osteomyelitis

Staging

• Orbital infections fall into one of five categories:

• Stage I - preseptal cellulitis• Stage II - orbital cellulitis• Stage III - subperiosteal abscess (which may arise from

orbital cellulitis or paranasal sinusitis)• Stage IV - orbital abscess (a complication of orbital

cellulitis)• Stage V - cavernous sinus thrombosis and infection (the

cavernous sinus drains venous blood from both eyes)

Management

• Adults: 250(qds) - 500(tds)mg oral co-amoxiclav depending on severity of infection, for 10 days with daily review until there is definite improvement (then every 2-7 days until complete recovery).

• Children: 20-40mg/kg/day oral co-amoxiclav over 24h in three divided doses.

• Lid abscesses should be drained.

• Hospital management may involve intravenous therapy (1-2gm iv ceftriaxone daily until response is seen)

Complications

• Progression to stage II and beyond of orbital infections.

• Unusually, lagophthalmos, lid abscess, cicatricial ectropion and lid necrosis may also be seen in these patients.

Prognosis

• Prompt diagnosis and treatment should result in an uncomplicated course and full recovery

Prevention

• Prophylactic antibiotics are prudent in the management of surgical and accidental trauma to the lid.

• Chloramphenicol ointment is a good first choice, applied qds to the clean wound for a week.

• Traumatic lid laceration also benefits from a review a 48-72h down the line to help identify any emerging preseptal cellulitis early.

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