The document provides an overview of preseptal and orbital cellulitis, detailing their definitions, causes, diagnosis, treatment, and potential complications. Preseptal cellulitis is an inflammation of the tissues in front of the orbital septum, primarily caused by bacterial infections, while orbital cellulitis refers to an infection behind the septum, often with more severe repercussions. Successful management depends on accurate diagnosis and prompt treatment, with outpatient care or hospitalization and intravenous antibiotics being key elements in treatment strategies.

1. PRESEPTAL CELLULITIS AND
ORBITAL CELLULITIS
DR. EUNICE
MD, MMED OPHTHALMOLOGY.

2. • PRESEPTAL CELLULITIS

3. • CONTENTS
• Disease entity
• Diagnosis
• Management
• Prognosis and Complications

4. Disease Entity
• Preseptal cellulitis is an inflammation of the tissues localized
anterior to the orbital septum.
• The orbital septum is a fibrous tissue that divides the orbit
contents in two compartments: preseptal and postseptal.
• The inflammation that develops posterior to the septum is known
as “orbital cellulitis”.
• Both entities are caused by an infectious process.

5. Pathophysiology
• There are three main routes for pathogen inoculation in the
periorbital tissues:
1.Direct inoculation: after eyelid trauma and infected insect bites.
2.Spread from contiguous structures: paranasal sinuses are the
most common.
3.Hematogenous: via blood vessels from an upper respiratory
tract or a middle ear infection.

6. Etiology
• The majority of these infections are caused by bacteria.
• In the immunocompromised patient we must suspect fungi as a possible etiology.
• Gram positive cocci are the most prevalent microorganisms identified in preseptal
cellulitis - typically Staphylococcus and Streptococcus species (pyogenes and
pneumonia).
• Staphylococcus aureus and epidermidis are commonly found after a penetrating
eyelid trauma.
• Streptococcus pneumoniae is a common etiology in preseptal cellulitis secondary to
sinusitis.

7. Diagnosis
• Eyelid swelling and redness.
• Malaise and low grade fever.
• Among the classic signs of preseptal cellulitis are eyelid edema/erythema/warmth and
fever.
• Difference between preseptal and orbital cellulitis:
• Preseptal cellulitis; eyelid edema and erythema, normal visual acuity, absence of proptosis,
pupil with normal reaction to light, normal color saturarion, normal conjunctiva and
normal ocular movements.
• Orbital cellulitis: eyelid edema and erythema, diminished visual acuity, proptosis is
present, relative afferent pupillary defect may be present, reduced color saturation,
chemotic conjunctiva and reduced extraocular movements with pain elicited by these
movements.

10. WORK UP
• Tests
• Complete blood count to document leukocytosis.
• CT scan: Sometimes the eyelid edema is so severe that precludes eye examination,
thus making the distinction between preseptal and orbital cellulitis impossible.
• In these cases, it is useful to order a CT scan of the orbit and sinuses (to diagnose
an associated sinusitis).
• Cultures of the eyelid wound (if evident), conjunctiva, blood (if febrile), abscess
contents (if present and drained) or paranasal sinus secretion. These are important
in order to prescribe the most appropriate antibiotic according to bacteria
sensitivity.
• Lymph nodes of the head and neck to asses for lymphadenomegaly.
• Check for signs of meningeal irritation to evaluate the presence of intracranial
complications.

11. • Differential diagnosis
• Orbital cellulitis
• Adenoviral keratoconjunctivitis
• Allergic conjunctivitis
• Contact dermatitis

12. Management
• General treatment
• Once diagnosed, preseptal cellulitis can be treated in an outpatient
or inpatient basis depending on the characteristics of the patient.
• If the patient is afebrile with a mild preseptal cellulitis he can be
followed as an outpatient with oral antibiotics and daily visits to
monitor the progress of the disease.
• If the patient does not respond to oral antibiotics in 48 hours or if
extension of the infectious process into the orbit is suspected, he
or she should be admitted to the hospital: a CT scan must be
performed to evaluate for orbital extension, and intravenous
antibiotics must be indicated.

13. • Children under 2 years of age or febrile patients with a
severe cellulitis are managed with intravenous antibiotics
during hospitalization, with close followup.
• Hospitalization is also recommended in patients who
cannot be followed up as outpatients.

14. • Broad spectrum antibiotics must be prescribed to cover gram positive and gram
negative bacteria.
• Oral
• Against gram positive and negative bacteria: Ampicillin, Amoxicillin/clavulanate,
Fluoroquinolones (levofloxacin), Azithromicin (also covers some anaerobic bacteria),
Clindamycin.
• Against gram positive (Staphylococcus) in case of an evident eyelid trauma:
Dicloxacillin, Flucloxacillin, first generation cephalosporins (cefalexine, cefazolin).
• Intravenous
• These antibiotics provide coverage to gram positive and gram negative bacteria.
• Third-generation cephalosporins (these medications are less sensitive to β-lactamase
producing bacteria such as S. aureus): Ceftriaxone, cefotaxime, ceftazidime.
• Ampicillin/sulbactam.

15. • Prognosis and Complications
• Prognosis is usually good when this entity is promptly diagnosed and treated.
• Orbital extension and complications: orbital cellulitis, subperiosteal abscess,
orbital abscess, cavernous sinus thrombosis.
• Central nervous system involvement (after orbital extension): meningitis,
abscesses (brain, extradural or subdural).
• Necrotizing fasciitis: it is a rare complication caused by β-hemolytic
Streptococcus. It presents as a rapidly progressive cellulitis with poorly
demarcated borders and violaceous skin discoloration, which can lead to
necrosis and toxic shock syndrome. The patient must be admitted to the
hospital, intravenous fluids should be replenished, IV broad spectrum
antibiotics must be prescribed and surgical debridement could be necessary.

16. ORBITAL CELLULITIS

17. Disease Entity
• Orbital cellulitis is an infection of the soft tissues of the eye
socket behind the orbital septum.
• Orbital cellulitis most commonly refers to an acute spread of
infection into the eye socket from either extension from
periorbital structures (most commonly the adjacent ethmoid or
frontal sinuses (90%), skin, dacryocystitis, dental infection,
intracranial infection), exogenous causes (trauma, foreign bodies,
post-surgical), intraorbital infection (endopthalmitis,
dacryoadenitis), or from spread through the blood (bacteremia
with septic emboli).

18. Risk Factors
• Upper respiratory illness.
• acute or chronic bacterial sinusitis.
• trauma, ocular or periocular infection, or systemic infection.

19. Pathogens
• The most common pathogens in orbital cellulitis are gram
positive Strep and Staph species.

20. Primary prevention
• Identifying patients and effectively treating upper
respiratory or sinus infections before they evolve into orbital
cellulitis is an important aspect of preventing
preseptal cellulitis from progressing to orbital cellulitis.
• Equally important in preventing orbital cellulitis is prompt
and appropriate treatment of preseptal skin infections as
well as infections of the teeth, middle ear, or face before
they spread into the orbit.

21. • Diagnosis
• The diagnosis of orbital cellulitis is based on clinical
examination. The presence of the following signs is
suggestive of orbital involvement:
• proptosis, chemosis, pain with eye movements,
ophthalmoplegia, optic nerve involvement as well as fever,
leukocytosis (75% of cases), and lethargy.
• Other signs and symptoms include rhinorrhea, headache,
tenderness on palpation, and eyelid edema. Intraocular
pressure may be elevated if there is increased venous
congestion.

22. • History
• The presence of a painful red eye, with lid edema in a child
with a recent upper respiratory infection is the typical
presentation of orbital cellulitis.
• Patient history should also include the presence of
headache, orbital pain, double vision, progression of
symptoms, recent upper respiratory symptoms (e.g. nasal
discharge or stuffiness), pain over sinuses, fever, lethargy,
recent periocular trauma or injury.
•

23. • history of sinus, ear, dental, or facial infections or surgery,
recent ocular surgery.
• presence of diabetes mellitus and the immune status of the
patient.
• Specific questions regarding any change in vision, mental
status, pain with neck movement, or nausea or vomiting
should also be asked.

24. • Physical examination
• The physical examination should include:
• Best-corrected visual acuity (BCVA). Decreased vision might
be indicative of optic nerve involvement or could be
secondary to severe exposure keratopathy or
retinal vein occlusion.
• Color vision assessment to assess the presence of optic
nerve involvement.
• Proptosis measurements.
• Visual field assessment via confrontation.

25. • Measurement of intraocular pressure (IOP). Increased
venous congestion may result in increased IOP.
• Slit-lamp biomicroscopy of the anterior segment if possible
to look for signs of exposure keratopathy in cases of severe
proptosis.
• Dilated fundus exam will exclude or confirm the presence of
optic neuropathy or retinal vascular occlusion

26. • Assessment of pupillary function with particular attention
paid to the presence of a relative afferent pupillary defect
(RAPD).
• .

27. • Signs
• Redness and swelling of the eyelid with a secondary ptosis.
• As the infection worsens, proptosis develops and extraocular motility becomes
compromised.
• When the optic nerve is involved, loss of visual acuity is noted and an afferent pupillary
defect can be appreciated.
• The intraocular pressure often increases.
• The skin can feel warm to the touch and pain can be elicited with either touch or eye
movements.
• Symptoms
• Systemic symptoms including fever and lethargy may or may not be present. Change in
the appearance of the eyelids with redness and swelling is frequently a presenting
symptom. Pain, particularly with eye movement, is commonly noted. Double vision may
also occur.

29. • Diagnostic procedures
• Computed tomography (CT) of the orbit is the imaging
modality of choice for patients with orbital cellulitis.
• Most of the time, CT is readily available and will give the
clinician information regarding the presence of sinusitis,
subperiosteal abscess, stranding of orbital fat, or
intracranial involvement.

30. • Laboratory test
• Admission to the hospital is warranted in all cases of orbital
cellulitis. A complete blood count with differential, blood
cultures, and nasal and throat swabs should be ordered.

31. Management
• General treatment
• Requires Admission to the hospital and initiation of broad-
spectrum intravenous antibiotics that address the most
common pathogens.
• Blood cultures and nasal/throat swabs may be undertaken,
and the antibiotics should be modified based on the results.
• In infants with orbital cellulitis, a 3rd generation
cephalosporin is usually initiated such as cefotaxime,
ceftriaxone or ceftazidime along with a penicillinase-
resistant penicillin.

32. • In older children, since sinusitis is most commonly
associated with aerobic and anaerobic organisms,
clindamycin might be another option.
• Metronidazole is also being increasingly used in children.

33. Surgery
• The prevalence of subperiosteal or orbital abscess complicating an orbital
cellulitis approaches 10%.
• observation with intravenous antibiotics only (i.e. no drainage of the
subperiosteal abscess) is indicated when:
• Child is under the age of 9 years
• No intracranial involvement
• Medial wall abscess is of moderate or smaller size
• No vision loss or afferent pupillary defect
• No frontal sinus involvement
• No dental abscess

34. • Complications
• severe exposure keratopathy with secondary ulcerative keratitis,
• neutrophic keratitis,
• secondary glaucoma,
• septic uveitis or retinitis,
• exudative retinal detachment, inflammatory or infectious
neuritis,
• optic neuropathy,
• panophthalmitis

35. • cranial nerve palsies, optic nerve edema,
• subperiosteal abscess,
• orbital abscess,
• central retinal artery occlusion, retinal vein occlusion,
blindness, meningitis, subdural or brain abscess, and death.

36. • Prognosis
• With prompt recognition and aggressive medical and/or
surgical treatment, the prognosis is excellent.

37. • References
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3.↑ Jump up to:3.0 3.1
Basic and Clinical Science Course 2019-2020: Pediatric Ophthalmology
and Strabismus. San Francisco, CA: American Academy of Ophthalmology; 2019.
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incidence. Otolaryngology–Head and Neck Surgery, 143(3), 392–396.
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