#45 – Preseptal vs Orbital Cellulitis



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Definitions

  • Orbital Septum
    • Membranous structure that extends from orbit to the tarsal plate and is the anterior boundary of the orbital compartment
  • Preseptal Cellulitis
    • Infection of the soft tissues ANTERIOR to the orbital septum
  • Orbital Cellulitis
    • Infections of the soft tissues POSTERIOR to the orbital septum

Numbers

  • Preseptal cellulitis is much more common than orbital (>90%)
  • Both conditions are more common in children than adults

Pathogenesis

  • Preseptal
    • Usually due to superficial dermatologic infections (though the data has wide variability in reported causes)
  • Orbital
    • Bacterial rhinosinusitis
      • Due to perforations in the lamina papyracea
    • Other causes:
      • Ophthalmologic surgery
      • Dacrocystitis
      • Orbital trauma
      • Dental infections

Microbiology

  • Preseptal
    • Staphylococcus aureus (skin causes)
      • Increasing incidence of MRSA
    • Streptococcus pneumoniae (sinus/nasopharynx causes)
  • Orbital
    • Same as preseptal, but include:
      • Fungal (mucormycosis and Aspergillus spp.)

Signs and Symptoms

  • Both present with unilateral eyepain, erythema, and edema, but:
  • Preseptal
    • No pain with eye movement
    • Sclera is white
Preseptal Cellulitis (sclera is white and quiet)

    • Orbital
      • Painful eye movement
      • Vision changes (acuity, diplopia)
      • Proptosis
      • Sclera injection and chemosis
      • Decreased pupillary response
Orbital cellulitis (notice sclera is red and angry with chemosis)

Complications

  • Complications of preseptal cellulitis are rare, but orbital cellulitis can lead to:
    • Vision loss (3-11%)
    • Subperiosteal abscess
    • Orbital abscess
    • Cavernous sinus thrombosis

Diagnostic Studies

  • CBC with differential may be helpful in risk stratification or atypical presentation
  • Preseptal
    • None! –> Clinical diagnosis
  • Orbital
    • Indications for CT scan
      • Inability to assess vision or deteriorating vision
      • Double vision
      • Inability to examine due to age
      • Proptosis
      • Restricted, limited, and/or painfuleye movement
      • Edema extending beyond eyelid margin
      • Lack of improvement in 24 hours on antibiotics
      • Cyclical fevers
      • Signs of CNS involvement
      • ANC > 10,000 cell/microL
a. proptosis, b. soft tissue inflammation, c. choroidal detachment, d. retrobulbar inflammation, e. optic nerve sheet enhancement
medial orbital subperiosteal abscess with left sided ethmoid sinusitis
  • Blood cultures are not routinely recommended but should be entertained in ill appearing children prior to antibiotic administration

Treatment

  • Preseptal
    • Outpatient
      • > 1 year old and no signs of systemic toxicity
      • Treatment duration typically 5-7days, but treatment should continue until eyelid erythema and swelling have resolved
    • Inpatient
      • < 1 year old, children who can’t cooperate with exam, toxic appearance, or outpatient treatment failing to improve in 24-48 hours
      • Follow orbital cellulitis treatment
  • Orbital
    • Medical
      • Staphylococcal coverage
        • Vancomycin
      • Streptococcal coverage
        • Ceftriaxone
        • Cefotaxime
      • Anaerobic coverage
        • Metronidazole
      • Improvement should occur within24-48 hours
      • Transition to oral therapy when:
        • Afebrile and periorbital signs are resolving
        • Typically 3-5 days
        • Follow culture data (if obtained) or follow outpatient preseptal cellulitis regimen
      • Treat for a total of 2-3 weeks
    • Surgical indications
      • Radiographically identified abscess
        • Typically > 10mm, though small abscesses respond to antibiotics well
      • Intracranial extension
      • Failure to respond to antibiotic treatment
      • Threat to vision


References

  1. Hauser A, Fogarasi S. Periorbital and orbital cellulitis. Pediatrics in review. 2010; 31(6):242-9. [pubmed]
  2. Botting AM, McIntosh D, Mahadevan M. Paediatric pre- and post-septal peri-orbital infections are different diseases. A retrospective review of 262 cases. International journal of pediatric otorhinolaryngology. 2008; 72(3):377-83. [pubmed]
  3. Horton JC. Disorders of the Eye. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison’s Principles of Internal Medicine, 20e New York, NY: McGraw-Hill; http://accessmedicine.mhmedical.com/content.aspx?bookid=2129&sectionid=192011900
  4. Chaudhry IA, Shamsi FA, Elzaridi E, Al-Rashed W, Al-Amri A, Arat YO. Inpatient preseptal cellulitis: experience from a tertiary eye care centre. The British journal of ophthalmology. 2008; 92(10):1337-41. [pubmed]
  5. Moran GJ, Krishnadasan A, Gorwitz RJ, et al. Methicillin-resistant S. aureus infections among patients in the emergency department. The New England journal of medicine. 2006; 355(7):666-74. [pubmed]
  6. Brook I, Frazier EH. Microbiology of subperiosteal orbital abscess and associated maxillary sinusitis. The Laryngoscope. 1996; 106(8):1010-3. [pubmed]
  7. Erickson BP, Lee WW. Orbital Cellulitis and Subperiosteal Abscess: A 5-year Outcomes Analysis. Orbit (Amsterdam, Netherlands). 2015; 34(3):115-20. [pubmed]
  8. Howe L, Jones NS. Guidelines for the management of periorbital cellulitis/abscess. Clinical otolaryngology and allied sciences. 2004; 29(6):725-8. [pubmed]
  9. Rudloe TF, Harper MB, Prabhu SP, Rahbar R, Vanderveen D, Kimia AA. Acute periorbital infections: who needs emergent imaging? Pediatrics. 2010; 125(4):e719-26. [pubmed]
  10. Tanna N, Preciado DA, Clary MS, Choi SS. Surgical treatment of subperiosteal orbital abscess. Archives of otolaryngology–head & neck surgery. 2008; 134(7):764-7. [pubmed]
  11. Greenberg MF, Pollard ZF. Medical treatment of pediatric subperiosteal orbital abscess secondary to sinusitis. Journal of AAPOS : the official publication of the American Association for Pediatric Ophthalmology and Strabismus. 1998; 2(6):351-5. [pubmed]

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