eMedicine Specialties > Ophthalmology > Orbit

Cellulitis, Preseptal

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

Introduction

Background

Preseptal cellulitis is a common infection of the eyelid and periorbital soft tissues characterized by acute eyelid erythema and edema. This bacterial infection usually results from local spread of adjacent upper respiratory tract infection, external ocular infection, or following trauma to the eyelids.

Pathophysiology

Periorbital inflammation is classified by location and severity. One of the major anatomical landmarks in determining the location of disease is the orbital septum. The orbital septum is a thin membrane that originates from the orbital periosteum and inserts into the anterior surfaces of the tarsal plates of the eyelids. The septum separates the superficial eyelid from the deeper orbital structures, and it forms a barrier that prevents infection in the eyelid from extending into the orbit. Preseptal cellulitis differs from orbital cellulitis in that it is confined to the soft tissues that are anterior to the orbital septum. Preseptal cellulitis may spread posterior to the septum and progress to form subperiosteal and orbital abscesses. Infection in the orbit can spread posteriorly and cause cavernous sinus thrombosis or meningitis.

Upper respiratory tract infections, especially paranasal sinusitis, commonly precede preseptal cellulitis. In 2 large case series, nearly two thirds of cases of cellulitis were associated with upper respiratory tract infection. One half of these cases were from sinusitis.

The most common organisms are Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus species, and anaerobes, reflecting the organisms that commonly cause upper respiratory tract infections and external eyelid infections. Blood and skin culture results tend to be negative.

Prior to the introduction of the Haemophilus influenzae type b (Hib) polysaccharide vaccine in 1985, H influenzae was the most common organism isolated in blood cultures. One study prior to the introduction of the vaccine noted that blood culture results were more likely to be positive (42%) if the patient had an upper respiratory infection and that subcutaneous aspirates were more likely to be positive (44%) if the patient had eyelid trauma or external ocular infection. Since the vaccine has come into widespread use, the rate of Haemophilus -positive blood cultures has dropped; studies report that the rate of any positive blood culture is now less than 4%. The reason that the rates for bacteremia for all organisms have dropped is unclear.

A study specifically looking at periorbital and orbital cellulitis since the advent of the vaccine likewise found that the rates of Hib-related cellulitis dropped from 11.7% to 3.5%. Total cases per year from all pathogens also declined, suggesting that H influenzae may have played a facilitative role in the pathogenesis of cellulitis.

In the era of concern about biologic warfare, it is also important to note that periorbital cellulitis has also been reported with both smallpox and anthrax.¹

Frequency

United States

In 1995, approximately 5000 US inpatients had an International Classification of Diseases, 9th revision (ICD-9), diagnosis of deep inflammation of the eyelid as a primary discharge diagnosis according to the NationalCenter for Disease Statistics.

Mortality/Morbidity

• Morbidity occurs from the spread of pathogens to the orbit, which can threaten vision and result in CNS spread. Untreated orbital cellulitis can lead to the development of an orbital abscess or can spread posteriorly to cause cavernous sinus thrombosis. Systemic spread of bacteria may lead to meningitis and sepsis.
• Earlier diagnosis, expeditious treatment, and improved antibiotics have led to a reduction of serious ocular and CNS complications.

Race

No known racial predilection exists.

Sex

No known sexual predilection exists.

Age

Preseptal cellulitis is primarily a pediatric disease with approximately 80% of patients younger than 10 years and most patients younger than 5 years. Patients with preseptal cellulitis tend to be younger than patients with orbital cellulitis.

Clinical

History

Patients may have mild-to-moderate temperature elevation. Although it has been suggested that orbital cellulitis generates a greater leukocytosis and febrile response than preseptal cellulitis, it is widely believed that these responses cannot be used to differentiate between the 2 conditions.

• Patients may complain of the following:
  • Pain
  • Conjunctivitis
  • Epiphora
  • Blurred vision
• Signs include periorbital erythema and edema (sometimes so severe that patients cannot voluntarily open the eye).

Physical

Because both orbital cellulitis and preseptal cellulitis can present with eyelid inflammation, it is important to perform a complete ocular examination. Be alert for signs of systemic illness, especially in children.

• The eyelids and ocular adnexa should be inspected for signs of local trauma. 
  • Cervical, submandibular, or preauricular lymphadenopathy may be present. A tender preauricular lymph node may be suggestive of adenoviral conjunctivitis.
  • Conjunctivitis may be present, and the quality of conjunctival drainage should be noted.
  • Test both vision and pupillary reactions in all patients presenting with eyelid inflammation, as evidence of limited motility or impaired vision suggests that inflammation has spread to the orbit.
  • An afferent pupillary defect suggests optic nerve compression, and immediate surgical drainage should be performed.
  • Resistance to retropulsion and proptosis suggest orbital involvement. An eyelid speculum may be needed to examine the eye and ocular movements.
  • The ocular fundus should be examined carefully for signs of optic nerve swelling and venous engorgement.
• Inspect for possible dacryocystitis² or dacryoadenitis, which can result in the spread of inflammation to adjacent tissues.
• Sinus tenderness, rhinorrhea, adenopathy, and other hallmarks of upper respiratory tract infection may be present.²

Causes

• Antecedent events may include the following recent eyelid lesions: 
  • Hordeola
  • Chalazia
  • Bug bites³
  • Trauma^3,2
  • Recent surgical procedures near the eyelids²
  • Oral procedures
• A concurrent or recent upper respiratory tract infection, especially sinusitis³ , may be present.
• Many systemic diseases have been reported with concurrent preseptal cellulitis.
  • Varicella
  • Asthma
  • Nasal polyposis
  • Neutropenia

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