Preseptal Cellulitis Workup

  • Author: Aaron L Sobol, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Mar 17, 2011
 

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.
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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.[5] 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.
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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.
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Histologic Findings

Biopsy shows edema and polymorphonuclear leukocytes infiltrating tissue planes.

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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.

Specialty Editor Board

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.

Simon K Law, MD, PharmD  Associate Professor of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

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.

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

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.

References

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This image shows a 10-year-old child who presented with fever, acute unilateral eyelid erythema, and limited extraocular motions. The presentation is suspicious for orbital cellulitis.
Preseptal cellulitis. This image shows an 8-year-old patient who presented with unilateral eyelid swelling and erythema.
 
 
 
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