Updated: 2/17/2021

Preseptal Cellulitis

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Snapshot
  • A 6-year-old boy presents to the pediatric emergency department for eye pain. A few days prior to presentation he was in a park and had a tick bite around his right eye. He has since developed right-eye swelling and pain. Physical examination is notable for periorbital warmth and erythema that is tender to palpation. Extraocular muscle eye movements are intact, not associated with pain, and there is no associated horizontal or vertical diplopia.
Introduction
  • Definition
    • infection of the anterior portion of the eyelid
      • does not involve the orbit fat or other ocular structures as in orbital cellulitis
      • considered a mild condition and is unlikely to result in serious complications
  • Epidemiology
    • incidence
      • more common than orbital cellulitis
    • demographics
      • children > adults
    • risk factors
      • sinusitis
      • focal trauma
      • insect or animal bites
  • Pathophysiology
    • direct inoculation of the microorganism
      • seen in cases of trauma and insect/animal bites
    • contiguous spread
      • infection involving the paranasal sinuses
        • especially the ethmoid sinuses
    • hematogenous spread
      • infection involving the upper respiratory tract or middle ear
  • Microbiology
    • Staphylococcus aureus
    • Streptococcus pneumoniae
    • other streptococci
    • anaerobes
  • Prognosis
    • great with prompt treatment
Presentation
  • Symptoms/physical exam
    • unilateral ocular pain
    • eyelid swelling
    • erythema of the eyelid
Imaging
  • CT scan of the orbits and sinuses
    • indication
      • cases where orbital cellulitis cannot be confidently excluded
Differential
  • Orbital cellulitis
    • differentiating factor
      • ophthalmoplegia
      • pain with ocular movements
      • proptosis
  • Dacryoadenitis 
    • differentiating factor
      • usually just involving the conjunctiva and lacrimal glands
      • skin around and inferior to the eye generally not affected
Treatment
  • Medical
    • empiric antibiotics
      • indications
        • oral antibiotics in mild cases without signs systemic toxicity
        • intravenous antibiotics in severely ill patients, children < 1 year of age, or in children who cannot fully cooperate during the exam (thus cannot exclude orbital cellulitis)
      • comments
        • trimethoprim-sulfamethoxazole or clindamycin with
          • amoxicillin, amoxicillin-calvulanic acid, cefpodoxime, or cefdinir 
        • antibiotics are typically administered for 5-7 days
        • blood cultures are not useful and it is difficult to obtain local cultures; therefore, antibiotics are empirically used against Staphylococcus and Streptococcus ssp.  
Complications
  • Although rare, can result in
    • orbital cellulitis
    • orbital or subperosteal abscess
    • cavernous sinus thrombosis
    • meningitis
    • brain abscess

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