Preseptal and orbital cellulitis are possible complications to paranasal sinusitis or trauma to the eye orbit. In preseptal cellulitis, the infection is limited to the eyelid and tissues posterior to the orbital septum; the condition is usually milder with pain, discoloration, and swelling; eye vision and ophthalmological examination are usually normal, and medical antibiotic therapy with oral antibiotics is sufficient. Patients with orbital cellulitis have fever, malaise, and proptosis ophthalmoplegia, which can be toxic; impaired vision; optic nerve edema; and they usually require inpatient treatment with intravenous antibiotics. Surgical intervention is more common with orbital cellulitis.
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Preseptal cellulitis

Image: “Periorbital cellulitis in 20 years old man.” by Afrodriguezg – Own work. License: CC BY-SA 3.0


Definition of Preseptal and Orbital Cellulitis

Orbital cellulitis is infectious inflammation of the posterior tissue to the orbital septum. Orbital fat, muscles, and even bony structures can be involved. Preseptal cellulitis differs from orbital cellulitis: the infected and involved tissues are anterior to the orbital septum.

Orbital cellulitis Preseptal cellulitis
Mixed flora
Include gram positives, gram negatives, anaerobes Usually GAS or staph
Requires broad-spectrum antibiotics Treat with narrow-spectrum antibiotics
Vision risk Rarely spreads into the eye if treated

Epidemiology of Preseptal and Orbital Cellulitis

Preseptal cellulitis is a more common condition when compared to orbital cellulitis, but the morbidity and complications of orbital cellulitis are more severe. Preseptal and orbital cellulitis are more common in children, with preseptal cellulitis occurring most often in children 5 to 10 years of age.

Preseptal cellulitis initiates superficially, whereas orbital cellulitis starts deeper in the septum of the orbit. A possible predisposing factor is a paranasal sinusitis. Patients typically have an extension of a paranasal or dental infection. Other possible risk factors include trauma, insect bites, and skin infections of the eyelid.

The most common risk factor for the 2 infections is similar, that being an infection that is often a direct extension of infected paranasal sinuses. In orbital cellulitis, however, eye surgery or trauma plays a significant role in predisposition to the condition. Metastatic spread of infection from other areas can also cause either condition.

Pathophysiology of Preseptal and Orbital Cellulitis

Patients can develop preseptal cellulitis due to a direct extension of infected paranasal sinuses to tissues anterior to the orbital septum. Spread of the infection in soft tissues such as the skin, subcutaneous fat, and eye adnexa is also common in the pathogenesis of preseptal cellulitis. Certain conditions such as dacryocystitis, sinusitis, and recent trauma or surgery to the eyelid or the eye itself can cause preseptal cellulitis.

However, orbital cellulitis can result from direct hematogenous spread of causative organisms, especially in patients with diabetes or in immunocompromised individuals. Patients can also develop the condition as a complication of direct extension of an infection from the paranasal sinuses separated by a partition of bone only. In one series, almost all patients with orbital cellulitis had some form of paranasal sinusitis. The infection is severe and extensive.

Patients can also develop the condition as a complication to eye surgery and direct inoculation of the eye with causative organisms. People with diabetes and other immunocompromised patients are at risk for orbital cellulitis as a complication from trauma to the eye, orbital bone fractures, or surgery to the eye. Orbital cellulitis can spread to cause cavernous sinus thrombosis, cerebral abscess, and meningitis.

Historically, the most common etiology of orbital and preseptal cellulitis was Haemophilus influenzae type b. Since the wide-spread introduction of H. influenzae vaccination, the organism is less likely to cause orbital cellulitis. Currently, the most commonly identified organisms in children with preseptal cellulitis are Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus. S. aureus and S. pneumoniae are also commonly identified in cases with orbital cellulitis. Patients who develop preseptal cellulitis present to the clinic complaining of a swollen eyelid due to eyelid edema, warmth, redness or discoloration of the eye and eyelid with or without fever, but with no protrusion of the eye. Visual examination reveals normal visual acuity with intact ocular movement and proptosis. Patients who develop orbital cellulitis are usually unable to move their eyes due to severe pain. Visual acuity might be impaired, and eye protrusion is common. Eyelid edema and redness can also be seen in orbital cellulitis, similar to preseptal cellulitis. In both conditions, patients might describe a recent history of upper respiratory tract infection or sinusitis. Patient history is essential for excluding other risk factors such as eye surgery or trauma to the orbit.

Staphylococcus-aureus

Image: “Staphylococcus aureus.“ by Y Tambe. License: CC BY-SA 3.0

Symptom Orbital Preseptal
Eyelid swelling, redness, discharge Yes Yes
Normal pupil response Yes Yes
Diplopia Common No
Abnormal eye movement Common No
Pain with eye movements Usually No
Proptosis Rare No

Diagnostic Workup for Preseptal and Orbital Cellulitis

As part of the evaluation of the patient presenting with preseptal or orbital cellulitis, a full ophthalmologic examination should be conducted. Visual acuity, pupillary response, intraocular pressure with tonometry, and ophthalmoscopy should be normal in patients with preseptal cellulitis, but might be impaired in patients with orbital cellulitis. Ophthalmoscopy can show optic nerve edema and posterior segment venous engorgement in patients with orbital cellulitis.

Imaging is essential in evaluating the patient presenting with possible orbital cellulitis. Magnetic resonance imaging (MRI) of the orbit can reveal soft tissue involvement, multiple loculations of the posterior segment of the eye, and signs of endophthalmitis. A computed tomography scan (CT) of the orbital bone can show orbital bone fractures, a possible risk factor for orbital cellulitis due to trauma. MRI is preferred to a CT scan if there is cavernous sinus thrombosis. Possible indications for orbital imaging include young age, significant periorbital edema, presence of fever, severe eye pain on movement, and presence of focal neurological signs. Focal neurological signs suggest spread of the infection to the central nervous system.

Blood cultures are preferred to ideally enable selection of the best antibiotic based on the microorganism detected. Lumbar puncture can be performed if meningitis is suspected.

Treatment of Preseptal and Orbital Cellulitis

Treatment options for preseptal and orbital cellulitis can either be medical or surgical. Medical management of preseptal cellulitis includes administration of adequate antibiotic therapy to treat the infection and limit its spread. Patients with mild preseptal cellulitis who are older than one year of age can be treated in an outpatient setting with oral antibiotics. Antibiotics of choice should cover the most commonly implicated organisms, S. aureus and Streptococcus spp.

Patients who have severe preseptal cellulitis or those who do not respond to oral antibiotic therapy should be admitted to the hospital for intravenous antibiotic therapy. Additionally, infants younger than one year of age who present with preseptal cellulitis should be treated in an inpatient setting regardless of the severity of the condition.

Methicillin resistant Staphylococcus aureus (MRSA) Bacteria

Image: “Scanning electron micrograph of methicillin-resistant Staphylococcus aureus (MRSA, brown) surrounded by cellular debris. MRSA resists treatment with many antibiotics.” by NIAID/NIH. License: Public Domain

Those who develop orbital cellulitis should always be treated in an inpatient setting with intravenous antibiotics. Patients suspected to have methicillin-resistant S. aureus should receive intravenous vancomycin. Combination therapy with intravenous cefotaxime, metronidazole, or clindamycin is usually indicated in cases of orbital cellulitis to cover gram-negative organisms and anaerobes.

Intranasal corticosteroids are indicated in cases of chronic sinusitis to facilitate nasal drainage. Treatment of sinusitis in cases of orbital cellulitis was found to provide an improved outcome especially in case of subperiosteal abscesses.

Surgical intervention in patients with preseptal cellulitis is rarely needed and is indicated in the case of the following:

  • Impairment of vision
  • Suspicion of pus formation or presence of foreign body
  • Evaluation of orbital or large subperiosteal abscess by imaging
  • Failure of antibiotics to resolve the infection

Patients who develop abscesses might need open drainage of the preseptal abscess. On the other hand, patients with orbital cellulitis are more likely to require surgical intervention to remove foreign bodies, bony fragments in case of orbital trauma, drain abscesses, or to remove an infected eye globe to avoid extension to other adjacent structures such as the central nervous system.

Preseptal  Orbital
Oral antibiotics usually sufficient Unasyn
Ceftriaxone and vancomycin if severe or eye-threatening
Cephalexin or clindamycin if allergic CT scan for abscess
Surgery if drainable abscess
Nose dops for sinuses (saline, α-agonist)
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