On Physical Examination, What Differentiates Preseptal and Orbital Cellulitis?

Patient Presentation
A 3-year-old female came to her doctor for a decreased appetite and swelling around her right eye.
She complained of pain in the right eye, cheek and head 1 day before.
That morning her right eye was swollen shut, was red and continued to be painful.
The past medical history showed a healthy child.
The review of systems revealed that 2 weeks prior she had a fever and upper respiratory tract infection with some swelling around her left eye at that time. All symptoms resolved.
The pertinent physical exam showed an somewhat ill-appearing pre-schooler with a temperature of 39.5 degree Celsius, heart rate 122, respirations 28 and a normal blood pressure.
There was erythema, edema and warmth of the skin of the right eye over the entire globe that extends medially across to the left cheek, distally to the bottom of the nose and laterally to a line parallel to the lateral eye canthus.
The sclera and palpebral conjunctiva were inflammed. There was full range of motion in the extraocular muscles bilaterally. Pupils were equal, round, reactive and 3-4 mm bilaterally. There is no photophobia. The rest of the examination was normal.
The radiologic evaluation included an orbital computed tomography scan which showed right-sided preseptal cellulitis with no bony or retro-orbital involvement.
The laboratory evaluation included a blood culture and a complete blood count that was normal except for a white blood cell count of 1.4 x 1000/mm2 with a 35% left shift.
The patient’s clinical course included admission for intravenous cefuroxime.
The patient continued to have significant pain, fevers in the 39-40 degree Celsius range and spread of the erythema radially in all directions over the next 36 hours.
The patient was transferred to a regional children’s hospital where the repeat orbital computed tomography examination showed the diagnosis of orbital cellulitis both pre- and post-septally with a possible subperiosteal abscess.
The abscess was successfully drained by Ophthalmology and a nasal-lacrimal duct stent was also placed to aid drainage.
The antibiotics were changed to intravenous ampicillin/sulbactam and after 5 days were changed to oral amoxicillin/clavulanic acid for a total of 14 days of antibiotics.
Cultures from the abscess and blood cultures were negative.

Figure 30 – Axial image from a CT scan of the orbits performed without intravenous contrast. The image shows extensive pre-septal and post-septal inflammatory changes around the right orbit. Sinusitis of the ethmoid and maxillary sinuses is also seen. Because intravenous contrast was not given, a subperiosteal abscess cannot be excluded.

Eye problems always raise concern with patients, families and health care providers because of the potential risk of vision loss. Thankfully, most problems are usually easily treated.

The orbital septum is a fascial layer extending vertically from the orbital rim periosteum to the levator aponeurosis in the upper eyelid and to the inferior border of the tarsal plate in the lower eyelid.

Preseptal cellulitis is anterior to the orbital septum is usually caused by Streptococcus species since the widespread immunization for Haemophilus influenzae type-B (HIB) which used to be the most common organism. Intravenous or oral antibiotics are usually given for 7-10 days.

Orbital cellulitis is posterior to the orbital septum and is a ophthalmologic emergency. It is usually secondary to sinusitis often arising from the ethmoid sinuses. The common organisms are: Streptococcus species, Staphlococcus aureus and HIB.
Generally children < 9 years have single organisms usually aerobic, but those > 9 years may have multiorganisms as the cause including anaerobes.
Evaluation includes consultation with an ophthalmologist, computed tomographs of the orbital structures and sinuses. Gram-stain, smears and cultures of eye or nose drainage, infected sinus or abscess should be obtained if available.
Broad spectrum antibiotics are usually given early in the clinical course for a duration of 2-3 weeks.
Potential complications include subperiosteal or orbital abscess with possible compression of the optic nerve and blindness. Surgical drainage for abscesses is often indicated but intensive antibiotics may also suffice.

Learning Point
Preseptal cellulitis (also known as periorbital cellulitis) and orbital cellulitis are common infections of the eye structures. It can be difficult to clinically differentiate between preseptal and orbital cellulitis, although computed tomography may be of some assistance. If there is any doubt, then treatment for orbital cellulitis is begun.

Preseptal cellulitis usually presents with usually well-demarcated edema and erythema of the periorbital skin and soft tissues.
Children may be ill-appearing and can be quite sick but generally are less ill-appearing than children with orbital cellulitis

With orbital cellulitis there characteristically is erythema and edema of the eyelids and periorbital tissues, painful eye movements, decreased vision, pupillary deficits and proptosis. The children are usually toxic appearing.

Figure 31 – Clinical image of orbital cellulitis.

In summary, both preseptal and orbital cellulitis may have:

  • Fever
  • Eyelid edema
  • Pain
  • Red eye
  • Child is ill-appearing

Orbital cellulitis often has:

  • Decreased eye movement
  • Decreased vision
  • Papilledema
  • Proptosis

The eyelid edema may be so significant that eyelid retractors are necessary to open the eyelids. Emergency eyelid retractors can be made from sterilized paperclips as shown below:

Figure 32 – Picture of eyelid retractors.

Questions for Further Discussion
1. What are other ophthalmologic emergencies?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

To view current news articles on this topic check Google News.

Fleisher GR, Ludwig S. Synopsis of Pediatric Emergency Medicine. Williams and Wilkins. Baltimore, MD. 1996:81-83, 735.

Hardus, P, et.al. Appropriate Technology in Ophthalmology. Intermediate Technology Information Ring. 1996. Available from the Internet at http://www.who.int/ncd/vision2020_actionplan/documents/ITIR1996booklet.pdf (rev. 7/1/05, cited 10/13/05).

Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1218, 2409.

Sobol AL. Preseptal Cellulitis. eMedicine.
Available from the Internet at http://www.emedicine.com/oph/topic206.htm (rev. 7/1/05, cited 10/13/05).

Centers for Disease Control. Public Health Image Library. Orbital Cellulitis. Image Number 2843. Available from the Internet at http://phil.cdc.gov (cited 10/13/05).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competency performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused case is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Donna M. D’Alessandro, MD
    Associate Professor of Pediatrics, Children’s Hospital of Iowa

    December 12, 2005