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Preseptal (Periorbital) Cellulitis

URGENT — Adnexa

Symptoms

  • tenderness, redness, warmth, and swelling of the eyelid
  • fever or chills (more common in children)

Preceding events

  • local skin trauma: abrasions, puncture wounds, or insect bites
  • adjacent infection: hordeolum (stye), dacryocystitis, or dental abscess
  • recent upper respiratory infection or sinusitis

Clinical Findings

Eyelid / periorbital

  • erythema (redness), tense edema, warmth, and significant tenderness
  • severe swelling may prevent the patient from opening the eye

Key negatives (must confirm to rule out orbital cellulitis)

  • NO proptosis (bulging of the eye)
  • NO pain with eye movement
  • NO restriction of extraocular motility (eye moves fully)
  • NO optic neuropathy (vision is normal, no rapd)
  • globe is white and quiet (minimal conjunctival injection)

Etiology

Common pathogens

  • staphylococcus aureus (including mrsa)
  • streptococcus species
  • haemophilus influenzae (consider in non-immunized children)

Specific scenarios

  • anaerobes: suspect if there is a foul-smelling discharge or an animal/human bite
  • viral: vesicular rash suggests hsv or vzv

Red Flags

  • any orbital sign: proptosis, ophthalmoplegia, or pain on motion → orbital cellulitis
  • pediatric toxic appearance: high fever or lethargy requires immediate admission
  • failed therapy: progression despite 48 hours of oral antibiotics
  • decreased vision/rapd: suggests optic nerve compromise from orbital pressure

Investigations

Clinical exam

  • meticulous assessment of motility, proptosis, and pupillary reactions
  • use a desmarres retractor if lids are too swollen to see the globe

Imaging (CT orbits with contrast)

  • indicated if: orbital signs present, child is febrile, trauma/foreign body suspected, or no improvement in 48h

Labs

  • cbc with differential and blood cultures (if febrile/toxic)
  • gram stain and culture of any open wound drainage

Treatment

Outpatient (mild disease)

  • amoxicillin-clavulanate: 875/125 mg po q12h (adults); 25–45 mg/kg/d (children)
  • mrsa coverage: trimethoprim-sulfamethoxazole (tmp-smx) or clindamycin

Inpatient (severe/pediatric/toxic)

  • iv ampicillin-sulbactam or vancomycin + ceftriaxone

Adjuncts

  • warm compresses for symptomatic relief
  • duration: typically 7–10 days of total antibiotic therapy

Clinical Pearl

preseptal vs orbital cellulitis: if the eye moves normally without pain and there is no proptosis, it is preseptal (safer). any doubt → ct orbits. children < 5 years are at higher risk of rapid progression to orbital involvement.

Differential Diagnosis

  • • orbital cellulitis (the most critical mimic)
  • • chalazion (localized, less toxic, no fever)
  • • allergic eyelid edema (itchy, pale swelling, no warmth/tenderness)
  • • necrotizing fasciitis (rapidly progressive, dusky/purple skin, crepitus)

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