Preseptal Cellulitis

Aka: Preseptal Cellulitis, Periorbital Cellulitis

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II. 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)

III. Epidemiology

  1. Typical onset at age 18 months to 3 years

IV. 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

V. Organisms

  1. Trauma
    1. Staphylococcus Aureus
    2. Group A Streptococcus
  2. Bacteremia (less common with modern Immunizations)
    1. Streptococcus Pneumoniae
    2. Haemophilus Influenzae

VI. 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

VII. 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

VIII. 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

IX. 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 controversial
    1. Sanford recommends starting with two agents, the second agent for added MRSA coverage
      1. Uptodate recommends single drug empiric coverage starting without MRSA (which they note is uncommon)
    2. Antibiotic 1 (choose one): Primary Preseptal Cellulitis coverage
      1. Amoxicillin-Clavulanate (Augmentin)
        1. Adult Immediate Release: 875 mg orally every 12 hours
        2. Adult Extended Release: 2000 mg orally every 12 hours
        3. Child: 45 mg/kg/day (90 mg/kg if resistance suspected) divided every 12 hours up to adult dosing
      2. Cefpodoxime (Vantin)
        1. Adult (and age >=12 years): 400 mg orally every 12 hours
        2. Child (age <12 years): 10 mg/kg/day divided every 12 hours orally (up to 200 mg/dose)
      3. Cefuroxime (Ceftin)
        1. Adult: 500 mg orally every 12 hours
        2. Child: 20 to 30 mg/kg/day (up to 1000 mg/day) orally divided twice daily
      4. Cefprozil (Cefzil)
        1. Identical dosing to Cefuroxime
      5. Cefdinir (Omnicef)
        1. Adult: 300 mg orally twice daily
        2. Child: 14 mg/kg/day (up to 600 mg/day) divided every 12 to 24 hours
      6. Levofloxacin (Levaquin)
        1. Adult: 600 mg orally daily
        2. Child: 10 to 20 mg/kg divided once to twice daily orally
          1. Relative contraindication due to risk of Arthropathy in juvenile animals
          2. However, human studies have not found signficant Arthropathy in children
    3. Antibiotic 2 (choose one): MRSA Coverage (per Sanford protocol)
      1. Trimethoprim Sulfamethoxazole (Septra, Bactrim)
      2. Doxycycline
      3. Clindamycin
  5. References
    1. (2023) Sanford Guide, accessed 7/1/2023
    2. Gappy and Archer (2024) Preseptal Cellulitis, Uptodate, accessed on IOS, 7/22/2024

X. 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

XI. References

  1. Williams (2017) Crit Dec Emerg Med 31(2): 3-12
  2. Broder (2023) Crit Dec Emerg Med 37(11): 20-2
  3. Givner (2002) Pediatr Infect Dis 21:1157-8 [PubMed]

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