Periorbital cellulitis or preseptal cellulitis is an infection most observed in the eyelid and the adjacent soft tissues. It is described by the development of generalized symptoms of inflammation and redness of the eyelid. It can be bacterial, viral, fungal or helminthic with bacterial being common due to adjacent sinusitis. Preseptal cellulitis is otherwise less severe than orbital cellulitis, which is infection behind the orbital septum that may present similarly at first. 

Preseptal cellulitis only involves the tissues in front of the orbital septum whereas orbital cellulitis involves tissues behind the septum. However, preseptal cellulitis can extend over the septum and can cause subperiosteal cellulitis, and orbital abscess. If it extends to the orbit, it may even extend to the cavernous sinus or the meninges which leads to serious consequences including cavernous sinus thrombosis or meningitis. 

Orbital cellulitis is known for its increased likelihood of complications and frequently calls for more intense management, such as surgical intervention if necessary. While preseptal cellulitis is not a surgical condition and it is treatable through medications. It is equally important to determine the place of inflammation to get an accurate diagnosis of the situation.  

In 1995 according to the data of the National Center for Disease Statistics, approximately 5000 in patients in the United States were mainly diagnosed with deep inflammation of the eyelid and according to ICD-9 classification. 

Preseptal cellulitis is common in children, as it is diagnosed in 80% of patients who are below the age of 10 years, and more than half of these are below the age of 5 years. It is usually associated with younger patients in comparison with orbital cellulitis. 

These include Staphylococcus aureus, Streptococcus pneumoniae, and Streptococcus pyogenes which are the common causes of periorbital cellulitis. This bacterium used to be prevalent, but with vaccination programs in place, its prevalence has gone down. However, there have been increased cases of infections resulting from methicillin-resistant Staphylococcus aureus (MRSA). Other bacteria that are less commonly associated with the disease are Acinetobacter, Nocardia, Bacillus, Pseudomonas, Neisseria, Proteus, Pasteurella, and Mycobacterium. However, invasive fungal infections including those caused by Mucorales and Aspergillus have also been reported. 

Periorbital cellulitis is usually associated with sinusitis, hematogenous spread, direct skin injury from an insect bite, periocular or facial trauma, and impetigo. Sinusitis pathogens, especially ethmoiditis, may invade neighboring structures by the ophthalmic venous system, which lacks valves, or through the thin lamina papyracea. Sinusitis has the tendency to cause complications on the periorbital or orbital areas and can also extend intracranially. 

Depending on the etiology, preseptal cellulitis can result from direct contamination with the pathogens or from contiguous spread. Many cases of orbital and preseptal cellulitis originate from upper respiratory tract infections, especially from paranasal sinusitis. In large case series, it was found that approximately two thirds of cellulitis could be attributed to upper respiratory tract infections and half of these were due to sinusitis. Dental abscesses are also considered a possible cause because they may also spread adjacent tissues. 

Common Causative Organisms 

The bacteria most frequently associated with preseptal cellulitis include: 

Staphylococcus aureus 

Staphylococcus epidermidis 

Streptococcus species 

Anaerobes 

These organisms are most frequently found in ailments affecting the upper respiratory tract and external infections of the eye lid. Nevertheless, culture from blood and skin samples in such cases does not always produce positive results. 

As with most conditions that are diagnosed early and treated properly, preseptal cellulitis has a very favorable prognosis in terms of the patient’s outcome without further complications. 

Orbital involvement poses further challenges that can potentially compromise vision or even result in CNS involvement. In the absence of treatment, orbital cellulitis may lead to an orbital abscess or progress to the rear part which leads to cavernous sinus thrombosis. Systemic bacterial spread could progress to meningitis and sepsis. 

A study of pediatric patients with intracranial infections identified high-risk features such as: 

Ocular trauma 

Age over 7 years 

Subperiosteal abscess 

Age Group 

Primarily Pediatric: Preseptal cellulitis is a common condition that mainly affects children since about 80% of cases present in patients younger than 10 years. The condition is particularly prominent in individuals who are aged below five years. 

General Examination 

Vital Signs: Take temperature, pulse, blood pressure and respiration rate for the identification of any sign of systemic infection (e. g., fever). 

General Appearance: Observe general patient behavior and agitation level. 

Ophthalmic Examination 

Eyelids: 

Unilateral Swelling: Look for excessive fluid accumulation of the eyelid which is commonly on one side only. 

Tenderness: Apply light pressure to detect whether the area is sore or irrational to the touch. 

Upper Respiratory Tract Infections: That is often preceded by URTIs, particularly sinusitis. 

Trauma: Conditions that cause minor trauma like bites from insects, scratches, or any region close to the eye may usually introduce bacteria, hence causing an infection. 

Skin Conditions: Preseptal cellulitis predisposing conditions include hordeola (styes), chalazia, and impetigo. 

Acute Onset: Preseptal cellulitis commonly occurs when there is an acute onset of its manifestations. 

Antibiotic Therapy 

Empirical Treatment: Start empirical antibiotic treatment directed at bacteria typically found to cause preseptal cellulitis, eg, Staphylococcus aureus, Streptococcus species, and anaerobes. 

First-Line Agents: For mild to moderate cases, oral antibiotics, like amoxicillin-clavulanate, cephalexin or dicloxacillin are commonly prescribed.
Severe Cases or High Suspicion of MRSA: Empiric coverage for MRSA with agents such as TMP-SMX, clindamycin and doxycycline should be given.
Intravenous Antibiotics: Used in patients with poor oral absorption capability, extreme conditions or for those who need to be hospitalized. The choice of antibiotics includes intravenous vancomycin, clindamycin, or ceftriaxone. 

Supportive Care 

Pain Management: These may include acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce pain. 

Warm Compresses: Suggest the use of warm compresses on the swollen area to help bring out the pus and reduce the size of the swelling. 

Ophthalmology

Warm Compresses: Applying warm compresses to the involved eyelid is beneficial for stimulating circulation at the site of the lesion, or to relieve pain and inflammation. Inform the patient or the caregiver to put a warm, clean washcloth onto the affected eyelid for ten to fifteen minutes, several times a day. Supports the removal of localized pus and may increase the efficacy of antibiotic use. 

Elevation: The head should be slightly raised during sleep to minimize edema and swelling around the eye. Remind the patient to use additional cushions to position the head slightly raised during sleep and any other time that he/she is lying down. Aids in removal of fluids and helps to decrease duration of periorbital oedema. 

Hydration and Rest: Taking enough water and adequate rest are critical in boosting the body immune system and general healing. Inform the patient to drink enough water and take a lot of rest to help in the healing process. Promotes healthy immune function and assists the body in its fight against various pathogens. 

Nutrition: Ensure proper diet to help build up the body’s immune system and for the general wellbeing of the patient in the recovery process. Avoid processed foods and consume foods that are high in vitamins and minerals, including fruits, vegetables, lean protein, and whole-grain foods. It also contains most of the nutrients required to produce tissue and for healing and fighting off bacteria and viruses. 

Ophthalmology

In fact, empirical therapy occupies a particularly important place in the initial approach to preseptal cellulitis because it allows covering several potential pathogens involved in the process. 

First-Line Oral Antibiotics: 

Amoxicillin-Clavulanate: Proven efficacy for covering a wide spectrum of gram-positive and gram-negative organisms that include β-lactamase producers. 

Cephalexin: Active against gram-positive cocci such as Staphylococcus aureus and the streptococcus group of bacteria. 

Dicloxacillin: In active to penicillinase producing Staphylococcus aureus. 

Ceftriaxone: Ceftriaxone belongs to the third generation of cephalosporins, it is a wide spectrum antibiotic that has shown less activity against gram-positive organisms but more activity against resistant gram-negative organisms which interacts with penicillin binding proteins. 

Naficillin: It is a second-generation penicillin that is approved for use in the treatment of penicillin G resistant Streptococcal or Staphylococcal infections. In severe instances, it should be administered in such a way that it needs to be given intravenously and transition to oral form if necessary. 

Ophthalmology

Preseptal cellulitis can be managed through incision and drainage (I&D), which is frequently employed throughout the healing process. It is used in the drainage of abscesses, in diagnosing cases of orbital involvement, and in managing complications. I&D is done to drain pus and relieve pressure in abscess cavities with the aim of enabling healing and decreased infection. It is applied in cases with abscess formation, lack of response to any medication treatment, or warning signs of orbital involvement or complications. This includes preparation, cutting, opening the abscess, cleaning the wound, taking sample, packing and finally follow up.

Ophthalmology

Assessment and Diagnosis: 

Clinical Evaluation: To rule out other underlying causes, it is crucial to take a detailed history and perform a thorough physical examination. Examine for signs like edematous eyelids, erythema, tenderness, and other general symptoms. 

Differential Diagnosis: Distinguish preseptal cellulitis from other conditions such as allergies, orbital cellulitis, or periorbital oedematous conditions. 

Initial Stabilization and Empirical Therapy: 

Prompt Initiation of Antibiotics: Begin the empirical antibiotic treatment early with specific reference to the most likely pathogens and the susceptibility profile to antibiotics of your geographical area. First-line treatment entails oral preparations including amoxicillin-clavulanate or cephalexin; intravenous preparations such as vancomycin or clindamycin may be appropriate if the infection is more severe or complicated by MRSA. 

Monitoring and Response Assessment: 

Clinical Monitoring: Assess the patient daily for changes, in symptoms and signs of infection which may include the extent of swelling and redness of the eyelids. 

Laboratory and Imaging Studies: Use imaging studies such as computed tomography when there is orbital involvement or abscess formation. 

Interventional Procedures: 

Incision and Drainage (I&D): To perform I&D for abscesses incise the abscess and evacuate pus and relieve this pressure especially if the antibiotic treatment fails or where there are abscesses.