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Preseptal and Orbital Cellulitis

Essentials

It is essential to distinguish between preseptal cellulitis (infection of the eyelid) and orbital cellulitis, where the infection has spread to the orbit, requiring immediate hospital treatment.
In both cases, the eyelid is inflamed but if examination of the eye reveals any abnormal findings, orbital cellulitis should be suspected.
For symptoms and findings, see Table T1.
See also Facial cellulitis in a child Facial Cellulitis in a Child.

Symptoms and findings of preseptal and orbital cellulitis

	Preseptal cellulitis	Orbital cellulitis
Eyelid	Erythema, oedema, ptosis	Erythema, oedema, ptosis
Conjunctiva	Normal or erythema, chemosis	Erythema, chemosis
Pupillary reactions	Normal	Normal or RAPD+^*
Vision, colour vision	Normal	Often reduced
Proptosis (protrusion of the eyeball)	No	Often yes
Eye movements	Normal	Restricted movement, pain on movement
Fever	None or mild	Often yes
Inflammatory laboratory values	Slightly elevated	High

*RAPD (Relative Afferent Pupillary Defect): When a light is shined alternately into each eye, the pupil on the inflamed side begins to dilate instead of constricting like the pupil on the healthy side.
Preseptal cellulitis Preseptal cellulitis is a purulent infection restricted to the eyelids (picture 1. Aetiology Most commonly due to infection spreading from an eyelid wound after injury or eyelid surgery. May also result from an infected chalazion, lacrimal sac or insect sting or bite. Impaired immunity or leaving the wound untreated will promote the spread of infection. The most common causative agents are staphylococci and streptococci and in unvaccinated people Haemophilus influenzae. Symptoms and findings The eyelid and periocular skin are red, warm and swollen, and there may be pus accumulation or skin necrosis. The patient may have a slightly elevated body temperature. Inflammatory markers (CRP, leucocytes) may be slightly or moderately elevated. Differential diagnosis The disease must be distinguished from orbital cellulitis. A chalazion Hordeolum and Chalazion is often localized. Allergic conjunctivitis Allergic Conjunctivitis typically involves itching. Certain types of viral conjunctivitis (Herpes simplex, shingles [Herpes zoster] and severe adenoviral conjunctivitis Conjunctivitis) often involve blisters and corneal changes. Acute dacryocystitis causes swelling and redness around the lacrimal sac in the inner canthus of the eye. Diagnosis Purulent and often widespread wound infection in the lid that can result in marked necrosis of the skin Differential diagnosis The disease must be differentiated from orbital cellulitis that causes pain, forward displacement of the eye and diplopia. Acute dacryocystitis causes swelling and redness around the lacrimal sac in the inner canthus of the eye and sometimes fever. Treatment In adults and children over 5 years systemic antimicrobial treatment most often orally for 7-14 days. Children below 5 years and MRSA carriers should be urgently assessed in specialized care. Antimicrobials to be used primarily (doses for adults given below) Amoxicillin-clavulanic acid (875/125 mg twice or three times daily) 500 mg cephalexin 3-4 times daily For people allergic to penicillin, sulpha-trimethoprim (160/500-800 mg twice daily) For MRSA carriers, additionally 1 g i.v. vancomycin twice daily. If the conjunctiva is red, topical chloramphenicol ointment or drops should be used. If there is a wound on the eyelid, it should be rinsed with water a couple of times a day and treated with chloramphenicol ointment. If there is an underlying injury, tetanus immunisation should be checked. Certain bacteria, such as group A beta-haemolytic streptococci, may cause necrotizing fasciitis. In that case, the patient should be referred as an emergency case to specialized care for surgical revision. Orbital cellulitis Orbital cellulitis is a purulent infection extending to the orbit. It is a condition threatening vision and sometimes even life and requires emergency treatment in specialized care. Aetiology Infection may spread to the orbit from surrounding tissue, most often the nasal sinuses, more rarely from teeth or from blepharitis. It may also originate from dacryocystitis, dacryoadenitis or intraocular infection. Infection may develop after orbital injury or surgery. It is rarely an infection spreading haematogenically from elsewhere in the body to the orbit. The causative agents are most commonly staphylococci or streptococci. Unvaccinated patients may also have Haemophilus influenzae infections. Gram-negative and anaerobic bacteria may be involved in infections originating in teeth or trauma. Fungi are possible causative agents in patients who have diabetes or are immunosuppressed. Symptoms and findings Oedema and redness in the eyelids, as in preseptal cellulitis. There are always also eye findings; see Table T1. Vision is often reduced, the eye protruded (proptosis), the orbit is taut, and intraocular pressure may be raised. There may be a relative afferent pupillary defect. Eye movements are painful and limited, and there is diplopia. There is often fever, and inflammatory markers are always clearly elevated. The infection may be life-threatening if it spreads through the orbital apex to the cavernous sinus, causing a thrombosis there. Differential diagnosis Graves' ophthalmopathy Graves' Ophthalmopathy Rapidly growing orbital tumours, and malformations Injuries (orbital haemorrhage and foreign bodies) Idiopathic orbital inflammatory disease (IOI) or specific orbital inflammation (such as dacryoadenitis, sarcoidosis, granulomatosis with polyangitis [GPA] or IgG4-related disease) Treatment Suspicion of orbital cellulitis is an indication for emergency referral to a hospital with consultation of an ophthalmologist, ENT specialist and paediatrician and radiographic facilities (CT or MRI) immediately available. From primary health care, adult patients should primarily be referred to an ENT specialist and paediatric patients to a paediatrician. An ophthalmologist and infectious diseases specialist should be consulted, as necessary. National/regional differences may apply. Emergency imaging is necessary (for adults, often CT, for children, MRI if immediately available). Samples should be taken from the nose, conjunctiva and any wounds or excretions. Treatment consists of broad-spectrum i.v. antimicrobials on the ward (adult doses given below). Primarily 1.5 g i.v. cefuroxime 3-4 times daily, also for patients with diabetes In infections of dental origin, additionally 500 mg i.v. metronidazole 3 times daily For MRSA carriers additionally 1 g i.v. vancomycin twice daily For patients with cephalosporin allergy 1 g i.v. vancomycin twice daily and 500 mg oral levofloxacin twice daily For patients with immunosuppression, consult an infectious diseases specialist. For sinusitis, nasal saline irrigation and nasal decongestants are used and irrigation of the sinuses considered. Surgical incision and drainage of any abscesses is typically performed. If the inflammation causes pressure on the optic nerve, treatment with glucocorticoids is considered after beginning antimicrobial medication. The patient's condition is monitored carefully every 4-8 hours until the situation becomes better. After that it is possible to change the antimicrobial medication to oral antimicrobials based on susceptibility testing for 1-2 weeks.