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Orbital vs Preseptal Cellulitis

Jonathan A. Barnett

Background

  • The septum is a fibrous, membranous structure that divides the anterior from the posterior orbit.

  • Preseptal cellulitis = infection is bound anterior to the septum

  • Orbital cellulitis (AKA postseptal cellulitis) = infection extends posterior to the septum

  • Common risk factors/etiologies: URI, acute or chronic sinusitis, trauma, tooth abscess, stye or other local/adjacent skin infection/condition, local/adjacent bug bite, immunocompromised state, underlying systemic infection

  • Often bacterial cause (gram positive Staph or Strep species, and/or gram negative anaerobic species like Peptococcus or Bacteroides). Consider fungal infection (Aspergillus, Mucor) in immunocompromised or diabetic patients.

Presentation

Preseptal Cellulitis Can be Present in Either Orbital Cellulitis

-Patient less toxic appearing

No visual compromise

-Mild conjunctival injection, no to minimal chemosis

-No or minimal limitation of eye movements

-No or minimal proptosis

-Symptoms improving with PO antibiotics

-Erythema and Edema of eyelids (upper and/or lower) and periorbital skin

-Fever (although more likely in Orbital cellulitis)

-Difficulty opening the eye d/t swelling

-Blurry vision

-Tearing/ocular discharge

-Patient more toxic appearing

-Pain with eye movements

-Limitation of eye movements +/- diplopia

-Proptosis

-Severe conjunctival injection + chemosis

-Vision may be compromised

-Symptoms not improving after course of PO antibiotics

Evaluation

  • Vital signs

  • Labs: CBC, CMP, ESR, CRP, blood cultures, wound culture if any open draining areas

  • Imaging: CT orbits with and without contrast

  • Daily or BID photographs to track progression

  • You can use the LRINEC scale to help assess whether the infection is necrotizing:

  • https://www.mdcalc.com/lrinec-score-necrotizing-soft-tissue-infection. Necrotizing soft tissue infections should be addressed immediately and undergo surgical debridement ASAP.

Management

  • Preseptal cellulitis can usually be managed on an outpatient basis with PO antibiotics (e.g. augmentin) with close followup.

  • However, if condition is worsening, if there is failure to improve on PO antibiotics, or if concerned for postseptal extension (i.e., that the preseptal cellulitis has evolved into an orbital cellulitis), management generally includes:

    • IV broad spectrum antibiotics (usually Unasyn + Vancomycin to start if no intracranial extension; could also do Vancomycin + Ceftriaxone + Flagyl)

    • Ophthalmology Consult

    • Consider ID consult

    • Consider ENT consult if concomitant sinus disease (most of the time there is)

    • Consider OMFS consult if suspect etiology is odontogenic

    • Tobradex eye drops QID to affected eye

    • Nasal toilet (afrin, flonase, nasal saline)--usually dictated by ENT

    • Warm compresses at least QID to affected eye

    • Trend daily CRP

  • If there is failure to improve on the above regimen, a large orbital abscess, optic nerve stretch on CT scan, evidence of necrotizing infection, or visual compromise, the patient may need to undergo surgical drainage.