Preseptal Cellulitis, also called periorbital cellulitis, is a bacterial infection of the eyelid and other soft tissues surrounding the eye. It usually is caused when an upper respiratory tract infection spreads to the eye area, but may also result from external ocular infection or soon after trauma to the area. This infection is most common in young children. Medscape reports that about 80 percent of patients with preseptal cellulitis are under 10 years of age, with most of those under five years of age. This is a common infection that is usually mild. Despite their rarity, though, complications can be serious. If the infection isn’t given appropriate treatment, it may spread behind the eyeball and result in a life-threatening condition called “orbital cellulitis,” which requires immediate hospitalization and the intravenous administration of antibiotics.
Classification and Complications
It is important to note the differences between the common preseptal and more serious orbital cellulitis, particularly because they share some symptoms. Preseptal or periorbital cellulitis affects the eyelid and surrounding soft tissue in front of the orbital septum (a thin membrane that separates the eyelid from deeper orbital structures and helps to block superficial infections from spreading into those deeper structures of the orbit). Orbital or postseptal cellulitis affects the areas behind the orbital septum. If preseptal cellulitis spreads posterior to the orbital septum, it can eventually cause permanent vision problems, neurological problems, or, if it spreads systemically, meningitis or sepsis. Both periorbital and orbital cellulitis are more common among children, but the former happens far more frequently than the latter. This is fortunate, considering the fact that preseptal cellulitis is usually much less severe than postseptal cellulitis, with the latter requiring aggressive treatment, often including surgery. Preseptal cellulitis on its own doesn’t cause permanent damage. For a person’s life or even vision to be seriously threatened, the bacteria must spread to the orbit. Early diagnosis and treatment can dramatically reduce the chances of the infection spreading.
The most common cause of preseptal cellulitis is when infection-causing bacteria enter the site through local trauma, such as a scratch, sty or insect bite. The most common bacteria to cause preseptal cellulitis are Streptococcus pneumoniae and various strains of Staphylococcus, including aureus and epidermidis. Upper respiratory tract infections, most commonly sinusitis, may cause preseptal cellulitis by spreading into the superficial tissues surrounding the eye. Some systemic diseases, such as varicella and asthma, are associated with preseptal cellulitis in both eyes.
Symptoms of both preseptal and postseptal cellulitis include acute pain in the eyelid, discoloration or redness, warmth and extensive swelling, which may make it difficult or even impossible to open the eye. Note that with preseptal cellulitis, vision will not actually be impaired while, with orbital cellulitis, both eye-movement and vision are affected. Additionally, fever, malaise and protopsis (protrusion of the eyeball) imply orbital cellulitis, as these symptoms would not accompany periorbital cellulitis. These symptoms will usually present themselves following upper respiratory tract infection or local trauma.
Preseptal cellulitis will be diagnosed by a clinical evaluation. Your physician will test your eye’s motility and acuity. If the eye is normal other than the swelling, preseptal cellulitis is the most likely culprit. Another clue is if there is a visible origin of infection on the skin. If the findings are ambiguous, which may happen especially with young children, an imaging test like a CT or MRI may be done to confirm orbital cellulitis and, if applicable, diagnose sinusitis.
Close observation and antibiotic therapy form the most common treatment plan for preseptal cellulitis. At first, therapy will be directed toward the pathogens that cause upper respiratory infections, especially sinusitis. Adults and older children in whom orbital celulitis has been definitively disqualified and who show no sign of systemic infection may be given the option of outpatient treatment. This is comprised of an oral antibiotic treatment plan that lasts about 10 days. If, however, the patient hasn’t responded within the first two to three days, IV treatment may be recommended. In severe cases or in younger children, hospitalization involving careful observation and intravenous antibiotics is the most likely treatment plan. This should last about seven days. If, however, there is no improvement within one to two days, or if the condition worsens, the possibility of orbital cellulitis or antibiotic-resistant pathogens (such as MRSA) will be considered. If the patient does improve within two to three days, discharge with continued outpatient treatment becomes a possibility. In the case of severe preseptal cellulitis with eyelid abscesses present, surgical drainage is possible. This is not usually necessary.