Preseptal Cellulitis Workup
- Author: Geoffrey M Kwitko, MD, FACS, FICS; Chief Editor: Edsel Ing, MD, FRCSC more...
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. Blood cultures are rarely necessary in preseptal and even orbital cellulitis, unless sepsis is suspected.
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 preseptal cellulitis from orbital cellulitis.
Samples of conjunctival discharge, eyelid lesions, and lacrimal sac material should be sent for culture.
In patients with pain disproportionate to signs and suspected periorbital necrotizing fasciitis, the laboratory risk indicator for necrotizing fasciitis (LRINEC), particularly markedly elevated C-reactive protein levels, may be of some utility.
Findings on examination that warrant imaging studies include pain on eye movement, afferent pupillary defect, limited extraocular motions, and resistance on retropulsion.
A computed tomography (CT) scan can delineate the extent of orbital involvement but is not necessary in all patients with preseptal cellulitis. Orbital ultrasonography 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. Orbital ultrasound very rarely, if ever, needed.
Consider lumbar puncture in all neonates and in patients with signs or symptoms of meningitis. Eyelid abscesses should be incised and drained if present.
Biopsy shows edema and polymorphonuclear leukocytes infiltrating tissue planes.
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, resistance on retropulsion, and arterialization of conjunctival blood vessels.
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 neurologic symptoms or neurologic 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. 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
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. 1993 Jan 13. 269(2):221-6. [Medline].
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. 2000 Aug. 107(8):1450-3. [Medline].
Barone SR, Aiuto LT. Periorbital and orbital cellulitis in the Haemophilus influenzae vaccine era. J Pediatr Ophthalmol Strabismus. 1997 Sep-Oct. 34(5):293-6. [Medline].
Donahue SP, Schwartz G. Preseptal and orbital cellulitis in childhood. A changing microbiologic spectrum. Ophthalmology. 1998 Oct. 105(10):1902-5; discussion 1905-6. [Medline].
Artac H, Silahli M, Keles S, Ozdemir M, Reisli I. A rare cause of preseptal cellulitis: anthrax. Pediatr Dermatol. 2007 May-Jun. 24(3):330-1. [Medline].
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. 2004 Mar. 137(3):554-6. [Medline].
Soysal HG, Kiratli H, Recep OF. Anthrax as the cause of preseptal cellulitis and cicatricial ectropion. Acta Ophthalmol Scand. 2001 Apr. 79(2):208-9. [Medline].
Babar TF, Zaman M, Khan MN, Khan MD. Risk factors of preseptal and orbital cellulitis. J Coll Physicians Surg Pak. 2009 Jan. 19(1):39-42. [Medline].
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. 2008 Oct. 92(10):1337-41. [Medline].
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. 2004 May. 20(3):217-23. [Medline].
Reynolds DJ, Kodsi SR, Rubin SE, Rodgers IR. Intracranial infection associated with preseptal and orbital cellulitis in the pediatric patient. J AAPOS. 2003 Dec. 7(6):413-7. [Medline].
Murthum K, Pogorelov P, Bergua A. [Preseptal cellulitis as a complication of surgical treatment of migraine headaches]. Klin Monatsbl Augenheilkd. 2009 Jul. 226(7):572-3. [Medline].
Agarwal M, Biswas J, S K, Shanmugam MP. Retinoblastoma presenting as orbital cellulitis: report of four cases with a review of the literature. Orbit. 2004 Jun. 23(2):93-8. [Medline].
Jacobs D, Galetta S. Diagnosis and management of orbital pseudotumor. Curr Opin Ophthalmol. 2002 Dec. 13(6):347-51. [Medline].
Finger Basak SA, Berk DR, Lueder GT, Bayliss SJ. Common features of periocular tinea. Arch Ophthalmol. 2011 Mar. 129(3):306-9. [Medline].
Borschitz T, Schlicht S, Siegel E, Hanke E, von Stebut E. Improvement of a Clinical Score for Necrotizing Fasciitis: 'Pain Out of Proportion' and High CRP Levels Aid the Diagnosis. PLoS One. 2015. 10 (7):e0132775. [Medline].
Ho CF, Huang YC, Wang CJ, Chiu CH, Lin TY. Clinical analysis of computed tomography-staged orbital cellulitis in children. J Microbiol Immunol Infect. 2007 Dec. 40(6):518-24. [Medline].
Eustis HS, Armstrong DC, Buncic JR, Morin JD. Staging of orbital cellulitis in children: computerized tomography characteristics and treatment guidelines. J Pediatr Ophthalmol Strabismus. 1986 Sep-Oct. 23(5):246-51. [Medline].
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. 2006 Sep. 69(9):415-22. [Medline].
Bababeygy SR, Silva RA, Sun Y, Jain A. Rifampin and linezolid in the treatment of methicillin-resistant Staphylococcus aureus preseptal cellulitis. Ophthal Plast Reconstr Surg. 2009 May-Jun. 25 (3):227-8. [Medline].
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].
Brugha RE, Abrahamson E. Ambulatory intravenous antibiotic therapy for children with preseptal cellulitis. Pediatr Emerg Care. 2012 Mar. 28 (3):226-8. [Medline].