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Preseptal Cellulitis Workup

  • Author: Geoffrey M Kwitko, MD, FACS, FICS; Chief Editor: Edsel Ing, MD, FRCSC  more...
 
Updated: Jun 16, 2016
 

Approach Considerations

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.[16]

Imaging

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.[17] 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.

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.

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CT Scanning

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

Staging [18]

A CT scan can delineate the extent of orbital involvement.[17] 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
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Contributor Information and Disclosures
Author

Geoffrey M Kwitko, MD, FACS, FICS Clinical Associate Professor, Department of Ophthalmology, University of South Florida College of Medicine

Geoffrey M Kwitko, MD, FACS, FICS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, International College of Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

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, American Society of Cataract and Refractive Surgery

Disclosure: Nothing to disclose.

Kelly A Hutcheson, MD, MBA Associate Professor, Department of Ophthalmology, George Washington University School of Medicine, Children's National Medical Center

Kelly A Hutcheson, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, Association for Research in Vision and Ophthalmology, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus

Disclosure: Nothing to disclose.

Chief Editor

Edsel Ing, MD, FRCSC Associate Professor, Department of Ophthalmology and Vision Sciences, University of Toronto Faculty of Medicine; Consulting Staff, Hospital for Sick Children and Sunnybrook Hospital

Edsel Ing, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Society of Ophthalmic Plastic and Reconstructive Surgery, Royal College of Physicians and Surgeons of Canada, Canadian Ophthalmological Society, North American Neuro-Ophthalmology Society, Canadian Society of Oculoplastic Surgery, European Society of Ophthalmic Plastic and Reconstructive Surgery, Canadian Medical Association, Ontario Medical Association, Statistical Society of Canada, Chinese Canadian Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

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.

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.

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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