eMedicine Specialties > Ophthalmology > Orbit

Cellulitis, Preseptal: Differential Diagnoses & Workup

Author: Aaron L Sobol, MD, Medical Director, Laurel Ridge Eyecare, Tulane University School of Medicine
Coauthor(s): Kelly A Hutcheson, MD, Associate Professor, Department of Ophthalmology, George Washington University School of Medicine, Children's National Medical Center,
Contributor Information and Disclosures

Updated: Nov 19, 2009

Differential Diagnoses

Cellulitis, Orbital
Herpes Simplex
Conjunctivitis, Bacterial
Herpes Zoster
Conjunctivitis, Viral
Hordeolum
Dacryoadenitis
Red Eye Evaluation
Dacryocystitis
Dermatitis, Contact

Other Problems to Be Considered

Rhabdomyosarcoma
Retinoblastoma
Orbital pseudotumor (idiopathic orbital inflammation)

Workup

Laboratory 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.4 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.

More on Cellulitis, Preseptal

Overview: Cellulitis, Preseptal
Differential Diagnoses & Workup: Cellulitis, Preseptal
Treatment & Medication: Cellulitis, Preseptal
Follow-up: Cellulitis, Preseptal
Multimedia: Cellulitis, Preseptal
References
Further Reading
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References

  1. Artac H, Silahli M, Keles S, Ozdemir M, Reisli I. A rare cause of preseptal cellulitis: anthrax. Pediatr Dermatol. May-Jun 2007;24(3):330-1. [Medline].

  2. Chaudhry IA, Shamsi FA, Elzaridi E, Al-Rashed W, Al-Amri A, Arat YO. Inpatient preseptal cellulitis: experience from a tertiary eye care centre. Br J Ophthalmol. Oct 2008;92(10):1337-41. [Medline].

  3. Babar TF, Zaman M, Khan MN, Khan MD. Risk factors of preseptal and orbital cellulitis. J Coll Physicians Surg Pak. Jan 2009;19(1):39-42. [Medline].

  4. Ho CF, Huang YC, Wang CJ, Chiu CH, Lin TY. Clinical analysis of computed tomography-staged orbital cellulitis in children. J Microbiol Immunol Infect. Dec 2007;40(6):518-24. [Medline].

  5. Liu IT, Kao SC, Wang AG, Tsai CC, Liang CK, Hsu WM. Preseptal and orbital cellulitis: a 10-year review of hospitalized patients. J Chin Med Assoc. Sep 2006;69(9):415-22. [Medline].

  6. Yang M, Quah BL, Seah LL, Looi A. Orbital cellulitis in children-medical treatment versus surgical management. Orbit. 2009;28(2-3):124-36. [Medline].

  7. Murthum K, Pogorelov P, Bergua A. [Preseptal cellulitis as a complication of surgical treatment of migraine headaches]. Klin Monatsbl Augenheilkd. Jul 2009;226(7):572-3. [Medline].

  8. Adams WG, Deaver KA, Cochi SL, Plikaytis BD, Zell ER, Broome CV, et al. Decline of childhood Haemophilus influenzae type b (Hib) disease in the Hib vaccine era. JAMA. Jan 13 1993;269(2):221-6. [Medline].

  9. Agarwal M, Biswas J, S K, Shanmugam MP. Retinoblastoma presenting as orbital cellulitis: report of four cases with a review of the literature. Orbit. Jun 2004;23(2):93-8. [Medline].

  10. Ambati BK, Ambati J, Azar N, Stratton L, Schmidt EV. Periorbital and orbital cellulitis before and after the advent of Haemophilus influenzae type B vaccination. Ophthalmology. Aug 2000;107(8):1450-3. [Medline].

  11. Barone SR, Aiuto LT. Periorbital and orbital cellulitis in the Haemophilus influenzae vaccine era. J Pediatr Ophthalmol Strabismus. Sep-Oct 1997;34(5):293-6. [Medline].

  12. Donahue SP, Schwartz G. Preseptal and orbital cellulitis in childhood. A changing microbiologic spectrum. Ophthalmology. Oct 1998;105(10):1902-5; discussion 1905-6. [Medline].

  13. Eustis HS, Armstrong DC, Buncic JR, Morin JD. Staging of orbital cellulitis in children: computerized tomography characteristics and treatment guidelines. J Pediatr Ophthalmol Strabismus. Sep-Oct 1986;23(5):246-51. [Medline].

  14. Hirsch M, Lifshitz T. Computerized tomography in the diagnosis and treatment of orbital cellulitis. Pediatr Radiol. 1988;18(4):302-5. [Medline].

  15. Hu G, Wang MJ, Miller MJ, Holland GN, Bruckner DA, Civen R, et al. Ocular vaccinia following exposure to a smallpox vaccinee. Am J Ophthalmol. Mar 2004;137(3):554-6. [Medline].

  16. Jackson K, Baker SR. Periorbital cellulitis. Head Neck Surg. Mar-Apr 1987;9(4):227-34. [Medline].

  17. Jacobs D, Galetta S. Diagnosis and management of orbital pseudotumor. Curr Opin Ophthalmol. Dec 2002;13(6):347-51. [Medline].

  18. Malinow I, Powell KR. Periorbital cellulitis. Pediatr Ann. Apr 1993;22(4):241-6. [Medline].

  19. McCarty ML, Wilson MW, Fleming JC, Thompson JW, Sandlund JT, Flynn PM, et al. Manifestations of fungal cellulitis of the orbit in children with neutropenia and fever. Ophthal Plast Reconstr Surg. May 2004;20(3):217-23. [Medline].

  20. Molarte AB, Isenberg SJ. Periorbital cellulitis in infancy. J Pediatr Ophthalmol Strabismus. Sep-Oct 1989;26(5):232-4; discussion 235. [Medline].

  21. Reynolds DJ, Kodsi SR, Rubin SE, Rodgers IR. Intracranial infection associated with preseptal and orbital cellulitis in the pediatric patient. J AAPOS. Dec 2003;7(6):413-7. [Medline].

  22. Ruttum MS, Ogawa G. Adenovirus conjunctivitis mimics preseptal and orbital cellulitis in young children. Pediatr Infect Dis J. Mar 1996;15(3):266-7. [Medline].

  23. Schwartz GR, Wright SW. Changing bacteriology of periorbital cellulitis. Ann Emerg Med. Dec 1996;28(6):617-20. [Medline].

  24. Soysal HG, Kiratli H, Recep OF. Anthrax as the cause of preseptal cellulitis and cicatricial ectropion. Acta Ophthalmol Scand. Apr 2001;79(2):208-9. [Medline].

  25. Weiss A, Friendly D, Eglin K, Chang M, Gold B. Bacterial periorbital and orbital cellulitis in childhood. Ophthalmology. Mar 1983;90(3):195-203. [Medline].

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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

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Contributor Information and Disclosures

Author

Aaron L Sobol, MD, Medical Director, Laurel Ridge Eyecare, Tulane University School of Medicine
Aaron L Sobol, MD is a member of the following medical societies: American Academy of Ophthalmology and American Society of Cataract and Refractive Surgery
Disclosure: Nothing to disclose.

Coauthor(s)

Kelly A Hutcheson, MD, Associate Professor, Department of Ophthalmology, George Washington University School of Medicine, Children's National Medical Center,
Kelly A Hutcheson, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Medical Editor

Brian A Phillpotts, MD, Former Vitreo-Retinal Service Director, Former Program Director, Clinical Assistant Professor, Department of Ophthalmology, Howard University College of Medicine
Brian A Phillpotts, MD is a member of the following medical societies: American Academy of Ophthalmology, American Diabetes Association, American Medical Association, and National Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

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
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Mark T Duffy, MD, PhD, Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic; Medical Director, Advanced Cosmetic Solutions, A BayCare Clinic
Mark T Duffy, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Sigma Xi, and Society for Neuroscience
Disclosure: Allergan - Botox Cosmetic Consulting fee Consulting; Quest medical - lacrimal balloons Honoraria Speaking and teaching; Ortho-Neutrogenia Consulting fee Consulting

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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