Preseptal Cellulitis

Aka: Preseptal Cellulitis, Periorbital Cellulitis

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II. Pathophysiology

  1. Preseptal Cellulitis is a Eyelid soft tissue infection
  2. Fibrous 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

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. HaemophilusInfluenzae

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. No Extraocular Movement pain or weakness (Ophthalmoplegia)
  3. No Proptosis
  4. Normal Vision
  5. Normal pupil reflexes
  6. No Conjunctival injection (Conjunctivitis)
  7. No cells and flare (Iritis)
  8. No limitation or pain on eye movement
  9. No Chemosis
  10. No retrobulbar globe pressure
  11. No Papilledema

VIII. Differential Diagnosis

  1. See Eyelid Inflammation
  2. Orbital Cellulitis

IX. Management

  1. Admit all cases of Orbital Cellulitis
  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. Antibiotic 1 (choose one)
      1. Clindamycin
      2. Trimethoprim Sulfamethoxazole (Septra, Bactrim)
    2. Antibiotic 2 (choose one)
      1. Amoxicillin-Clavulanate (Augmentin)
      2. Cefpodoxime (Vantin)
      3. Cefuroxime (Ceftin)
      4. Cefprozil (Cefzil)
      5. Cefdinir (Omnicef)

X. Complications

  1. Orbital Cellulitis (from contigious extension)
  2. Intracerebral extension of Preseptal Cellulitis is rare without Orbital Cellulitis extension
    1. Protective fibrous layer prevents extension

XI. References

  1. (2023) Sanford Guide, accessed 7/1/2023
  2. Williams (2017) Crit Dec Emerg Med 31(2): 3-12
  3. Givner (2002) Pediatr Infect Dis 21:1157-8 [PubMed]

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