Alan R. Forman

BASICS

DESCRIPTION

• An infection of the eyelid and surrounding skin anterior to the orbital septum. By definition, the infection does not involve intraorbital tissue.

• Synonym: Periorbital cellulitis

Pediatric Considerations

• Preseptal cellulitis can lead to visual impairment in very young children if prolonged eyelid edema leads to occlusion amblyopia.

• If physical exam is difficult, imaging may be required to rule out orbital cellulitis. After trauma, if the eye cannot be adequately examined, an exam under anesthesia is mandatory to rule out a ruptured globe.

• Ask about vaccinations, especially Haemophilus influenzae type B.

EPIDEMIOLOGY

• Predominantly affects the pediatric age group

• Most younger than 5 years; mean age is 21 months (1)

• Occurs more commonly in the winter months

• No known predilection for gender or race

RISK FACTORS

• Adjacent infection or trauma (see “Etiology”)

• Sinusitis

• Surgical procedure near the eyelid

• Oral procedures

• Poorly controlled diabetes mellitus

• Immunocompromised patients

GENERAL PREVENTION

• Childhood vaccination for H. influenzae type B

• Proper detection and early treatment of sinus, dental, ear, and other adjacent infections

PATHOPHYSIOLOGY

• Preseptal cellulitis is an infection anterior to the orbital septum. The orbital septum largely prevents the spread of infection to the orbit and CNS. Any preseptal infection can extend back into the orbit.

• Routes of infection include direct inoculation from trauma or the spread of an adjacent infection.

• Streptococcus pneumoniae is the most frequent pathogen associated with sinus infection while Staphylococcus aureus and Streptococcus pyogenes predominate when infection arises from local trauma.

ETIOLOGY

• Adjacent infection

– Most commonly from the spread of infection from paranasal sinuses

– Other infectious sources include hordeolum, acute chalazion, dacryocystitis, dacryoadenitis, teeth or gums, or impetigo

• Trauma

– Insect or animal bites, lacerations, puncture wounds, or retained foreign bodies

• Causative organisms

– The most common bacterial agent identified in children is S. pneumoniae followed by S. aureus and S. pyogenes.

– Prior to introduction of the H. influenzae type B vaccine, H. flu was the most common cause of preseptal and orbital cellulitis.

– With a human or animal bite, suspect anaerobic, non-spore–forming bacteria

– Polymicrobial infections are more common in older patients (>15 years) and in open wounds.

– Methicillin-resistant S. aureus (MRSA) must be considered in at-risk populations, especially with trauma.

– Fungi (mucormycosis, aspergillosis) possible in immunocompromised patients

– Clostridial gas gangrene if soil contamination

COMMONLY ASSOCIATED CONDITIONS

• A concurrent or recent upper respiratory tract infection (URI), especially sinusitis (2)

• Chronic staphylococcal blepharitis

• Anthrax and smallpox vaccinations have rarely been linked to preseptal cellulitis (3).

DIAGNOSIS

HISTORY

• Recent trauma, surgery, or nearby infection

• Recent URI, sinus infection, or ear infection

• Pain with eye movement or change in vision

• Constitutional symptoms (e.g., fever, nausea)

• Vaccination status (especially H. Flu type B)

• Prior cancer diagnosis

PHYSICAL EXAM

• Vital signs

• Comprehensive ocular examination

– Note any restrictions of ocular motility or proptosis, suggesting an orbital process.

– Record visual acuity, pupillary reaction, eye pressure, and optic nerve head appearance.

• Palpate the periorbital area and the head and neck lymph nodes.

• Note any tenderness, swelling, warmth, redness, or discoloration of the eyelid.

• Assess for neurological deficits.

• Check for meningeal signs.

• Thorough examination of the globe is required in all patients with any history of trauma to rule out a ruptured globe.

DIAGNOSTIC TESTS & INTERPRETATION

Lab

Initial lab tests

• In all cases, obtain a culture and Gram stain of any open wound or drainage.

• In severe cases or with constitutional symptoms, obtain a CBC count with differential, two sets of blood cultures, and CT scan (see “Imaging”).

• If patient exhibits CNS signs, obtain CSF after an intracranial mass is ruled out.

Follow-up & special considerations

If patient deteriorates clinically, consider orbital cellulitis and hospital admission.

Imaging

Initial approach

• CT scan, with contrast if possible, of the brain and orbits (axial and coronal views) in any one of the following scenarios:

– Possible orbital involvement or proptosis

– A history of significant trauma

– Concern of an orbital or intraocular foreign body

– There is high suspicion for subperiosteal abscess/paranasal sinusitis/cavernous sinus thrombosis/cancer.

Follow-up & special considerations

Consider ordering a repeat or initial CT scan if the patient does not improve in 24–48 h with appropriate antibiotic therapy or if the patient begins to clinically deteriorate

DIFFERENTIAL DIAGNOSIS

• Orbital cellulitis

• Allergic edema of eyelids

• Viral conjunctivitis

• Erysipelas

• Necrotizing fasciitis (Gr A Beta hemolytic Strep)

• Cavernous sinus thrombosis

• Herpes simplex or herpes zoster blepharitis

• Idiopathic orbital inflammatory syndrome

• Other possibilities: thyroid eye disease, leukemic infiltrates, blepharochalasis, and autoimmune inflammatory disorders

TREATMENT

MEDICATION

First Line

• Hospitalize patients younger than 1 year.

• Milder cases of preseptal cellulitis in adults and children older than 1 year with no signs of systemic toxicity, adequate vaccination status, and who are reliable for follow-up visits can be managed on an outpatient basis (4)[C]. Initial daily follow-up is required (see “Follow-up Recommendations”)

– Amoxicillin/clavulanate (e.g., Augmentin) can be used in children and adults.

– For children, 20–40 mg/kg/day PO t.i.d. For adults, 500 mg PO q8h

– Trimethoprim/sulfamethoxazole (e.g., Bactrim) should be considered in MRSA suspected infections or in penicillin allergic patients.

– For children, dosage is 8–12 mg/kg/day trimethoprim with 40–60 mg/kg/day sulfamethoxazole PO b.i.d.

– For adults, 160–320 mg trimethoprim with 800–1,600 mg sulfamethoxazole PO, b.i.d.. Doxycycline is an alternative in nonpregnant adults only (100 mg PO, b.i.d.)

– Recommended duration of broad-spectrum oral antibiotics is 7–10 days (5)[C].

Second Line

• For children or adults with penicillin allergies, trimethoprim/sulfamethoxazole can be substituted (see “First Line” for dosing)

• For adults only, moxifloxacin (400 mg PO daily) can be substituted.

ADDITIONAL TREATMENT

General Measures

• Hot compresses

• Incision and drainage of localized eyelid abscess if present (see “Surgery”)

Issues for Referral

• Ophthalmology consultation is advised for moderate to severe cases and all pediatric cases.

• ENT consultation is suggested for medical and surgical treatment of sinusitis.

Additional Therapies

If patient is on broad-spectrum antibiotics and flocculence or abscess detected, then low-dose, short-duration adjunct corticosteroids can be given in the absence of retained foreign body.

SURGERY/OTHER PROCEDURES

• A lid abscess may complicate preseptal cellulitis and can be surgically drained in an outpatient setting with alert cooperative patients.

– Pus obtained from wounds or abscess cavities: directly inoculate onto blood agar, chocolate agar, and an anaerobic medium

IN-PATIENT CONSIDERATIONS

Initial Stabilization

• Patients with severe cases or less than 1 year of age should be initially managed as an orbital cellulitis with a CT scan, IV broad-spectrum antibiotics, and hospital observation (6).

– IV antibiotic choices include ampicillin/sulbactam or ceftriaxone. Consider local trends in antimicrobial therapy. If MRSA is suspected or if patient is allergic to penicillin, consider vancomycin.

– Choice of specific IV antibiotic depends on the results of Gram stain and culture.

Admission Criteria

• Children younger than 1 year (6)[B]

• Orbital cellulitis is suspected

• Patient appears toxic

• Patient may be noncompliant with outpatient treatment or follow-up

• Clinical deterioration or no noticeable improvement after 48 h of oral antibiotics

Nursing

• Continue monitoring vitals and symptoms.

• Alert physician if patient develops worsening signs of toxicity, orbital involvement, changes in visual acuity, or neurological signs.

Discharge Criteria

• IV antibiotics can be switched to comparable oral antibiotics and monitored on an outpatient basis after significant improvement is observed.

• Patient should be afebrile for a minimum of 24 h before switching to oral antibiotics or afebrile for 48 h if blood cultures were positive.

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

• Daily outpatient visits are necessary until consistent improvement is demonstrated, then followed every 2–7 days until total resolution.

• Cell phone photographs may be useful during this period for monitoring.

Patient Monitoring

Observe for signs of worsening infection, orbital cellulitis, and/or systemic toxicity

PATIENT EDUCATION

Patients are advised to receive immediate care if they experience systemic toxicity, worsening visual acuity, or pain with eye movements.

PROGNOSIS

Prognosis for complete recovery is excellent in patients identified and treated promptly.

COMPLICATIONS

• Infection may spread along tissue planes and progress to orbital cellulitis, subperiosteal abscess, orbital abscess, intracranial infection, and cavernous sinus thrombosis.

• Immunocompromised patients are more likely to develop potentially fatal fungal infections and should be monitored more aggressively.

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