Background

Preseptal cellulitis is a common infection of the eyelid and periorbital soft tissues that is
characterized by acute eyelid erythema and edema. Preseptal cellulitis may be caused by
bacteria, viruses, fungi, or helminths. Bacterial infections may result from local spread of an
adjacent sinusitis or dacryocystitis, from an external ocular infection, or following trauma to
the eyelids (see the image below). (See Etiology and Presentation.)
Preseptal cellulitis. This image shows an 8-year-old patient who presented with
unilateral eyelid swelling and erythema.
Preseptal cellulitis tends to be a less severe disease than orbital cellulitis (postseptal
cellulitis), which can have a similar initial presentation. Preseptal cellulitis differs from
orbital cellulitis in that it is confined to the soft tissues that are anterior to the orbital septum.
Preseptal and orbital cellulitis can be a continuum. Preseptal cellulitis can spread posterior to
the septum, progressing to form subperiosteal and orbital abscesses. Infection in the orbit can
spread posteriorly and cause cavernous sinus thrombosis or meningitis. (See Prognosis,
Presentation, and Workup.)
Orbital cellulitis has a higher morbidity, requires aggressive treatment, and may require
surgical intervention, whereas preseptal cellulitis usually is managed medically. Delineation
of the exact location of inflammation is necessary for proper diagnosis and treatment. (See
Prognosis and Treatment.) Pain or limited eye movement, chemosis, afferent pupil, or
resistance to retropulsion indicates orbital extension of the infection.

Orbital septum
Periorbital inflammation is classified by location and severity. One of the major anatomical
landmarks in determining the location of disease is the orbital septum. The orbital septum is a
thin membrane that originates from the orbital periosteum and inserts into the anterior
surfaces of the tarsal plates of the eyelids. The septum separates the superficial eyelid from
the deeper orbital structures, and it forms a barrier that prevents infection in the eyelid from
extending into the orbit.

Patient education
Patients should be instructed that loss of vision or pain with eye movements is an indication
that the infection has spread to the orbit and may necessitate surgical intervention. Increased
edema and redness or pain in general are also warning signs.
For patient education information, see the Diabetes Center, as well as Cellulitis.

Etiology

Upper respiratory tract infections, especially paranasal sinusitis, commonly precede orbital
cellulitis and some cases of preseptal cellulitis. In 2 large case series, nearly two thirds of
cases of cellulitis were associated with upper respiratory tract infection. One half of these
cases were from sinusitis.
The most common organisms are Staphylococcus aureus, Staphylococcus
epidermidis,Streptococcus species, and anaerobes, reflecting the organisms that commonly
cause upper respiratory tract infections and external eyelid infections. Blood and skin culture
results tend to be negative.
Prior to the introduction of the Haemophilus influenzae type b (Hib) polysaccharide vaccine,
in 1985, H influenzae was the most common organism isolated in blood cultures.[1, 2, 3, 4] One
study prior to the introduction of the vaccine noted that blood culture results were more likely
to be positive (42%) if the patient had an upper respiratory infection and that subcutaneous
aspirates were more likely to be positive (44%) if the patient had eyelid trauma or external
ocular infection.
Since the vaccine came into widespread use, the rate of Haemophilus -positive blood cultures
has dropped; studies have reported that the rate of any positive blood culture is now less than
4%. The reason that the rates for bacteremia for all organisms have dropped is unclear.
A study specifically looking at periorbital and orbital cellulitis since the advent of the vaccine
likewise found that the rates of Hib-related cellulitis dropped, from 11.7% to 3.5%. Total
cases per year from all pathogens also declined, suggesting that H influenzae may have
played a facilitative role in the pathogenesis of cellulitis.
In an era of concern about biologic warfare, it is also important to note that periorbital
cellulitis has also been reported with smallpox and anthrax.[5, 6, 7]

Risk factors
Antecedent events in preseptal cellulitis may include the following recent eyelid lesions:

Hordeola

Chalazia

Bug bites [8]

Trauma-related lesions [9, 8]

Lesions caused by a recent surgical procedure near the eyelids [9]

Lesions caused by oral procedures

Dacryocystitis

An upper respiratory tract infection, especially sinusitis,[8] may be present concurrently with
preseptal cellulitis or may have recently occurred. Many systemic diseases have been
reported with concurrent preseptal cellulitis, including the following:

Varicella

Asthma

Nasal polyposis

Neutropenia [10]

Epidemiology
According to the National Center for Disease Statistics, in 1995, approximately 5000
inpatients in the United States had a primary discharge diagnosis of deep inflammation of the
eyelid, as specified in the International Classification of Diseases, 9th revision (ICD-9).
Preseptal cellulitis is primarily a pediatric disease, with approximately 80% of patients being
younger than 10 years and most patients being younger than 5 years. Patients with preseptal
cellulitis tend to be younger than patients with orbital cellulitis.

Prognosis
If preseptal cellulitis is identified and treated promptly, the prognosis for complete recovery
without complication is excellent.
Morbidity occurs from the spread of pathogens to the orbit, which can threaten vision and
result in central nervous system (CNS) spread. Untreated orbital cellulitis can lead to the
development of an orbital abscess or can spread posteriorly to cause cavernous sinus
thrombosis. Systemic spread of bacteria may lead to meningitis and sepsis.
In a study of pediatric patients with intracranial infection, high-risk features included the
following[11] :

Age older than 7 years

Subperiosteal abscess

Headache [12] and fever persisting despite the use of intravenous (IV) antibiotics

Patients who are immunocompromised or diabetic have a higher likelihood of developing

fungal infections, which can rapidly become fatal. Aggressive management, including
imaging studies of the brain and early IV therapy, along with a high index of suspicion, is
indicated for these patients. Otolaryngologist consultation also should be ordered if fungal
infection is suspected.

History
Patients may have mild to moderate temperature elevation. Although it has been suggested
that orbital cellulitis generates a greater leukocytosis and febrile response than preseptal
cellulitis does, it is widely believed that these responses cannot be used to differentiate the 2
conditions from each other.
Patients may complain of the following:

Pain

Conjunctivitis

Epiphora

Blurred vision

Signs of preseptal cellulitis include periorbital erythema and edema (sometimes so severe that
patients cannot voluntarily open the eye).
Following periorbital trauma, foreign body should be excluded.
In febrile patients with pain disproportionate to clinical findings, periorbital necrotizing
fasciitis should be considered.

Physical Examination
Because orbital cellulitis and preseptal cellulitis can each present with eyelid inflammation, it
is important to perform a complete ocular examination. Be alert for signs of systemic illness,
especially in children.
The eyelids and ocular adnexa should be inspected for signs of local trauma. Cervical,
submandibular, or preauricular lymphadenopathy may be present. A tender preauricular
lymph node may be suggestive of adenoviral conjunctivitis. Conjunctivitis may be present,
and the quality of conjunctival drainage should be noted.
Test vision and pupillary reactions in all patients who present with eyelid inflammation, as
evidence of limited motility or impaired vision suggests that the inflammation has spread to
the orbit. A relative afferent pupillary defect suggests optic nerve compression, and
immediate surgical drainage should be performed.
Resistance to retropulsion and proptosis suggest orbital involvement. An eyelid speculum
may be needed to examine the eye and ocular movements.
The ocular fundus should be examined carefully for signs of optic nerve swelling and venous
engorgement.

Inspect for possible dacryocystitis[9] or dacryoadenitis, which can result in the spread of
inflammation to adjacent tissues.
Sinus tenderness, rhinorrhea, adenopathy, and other hallmarks of upper respiratory tract
infection may be present.[9]

Diagnostic Considerations
Problems to be considered in the differential diagnosis of preseptal cellulitis include the
following:

Rhabdomyosarcoma

Retinoblastoma[13]

Orbital pseudotumor (idiopathic orbital inflammation)[14]

Periocular tinea[15]

Herpes simplex

Herpes zoster

Ruptured dermoid cyst

Cerebrospinal fluid leakage (eg, following trauma)

Differential Diagnoses

Allergic Contact Dermatitis

Bacterial Conjunctivitis

Carotid Cavernous Fistula

Dacryoadenitis

Dacryocystitis

Herpes Simplex in Emergency Medicine

Herpes Zoster

Hordeolum

Orbital Cellulitis

Red Eye Evaluation

Viral Conjunctivitis

Approach Considerations
Blood culture results are positive in less than 10% of cases of preseptal cellulitis. Prior to the
introduction of the Hib vaccine, blood cultures were positive in up to one third of patients.
Blood cultures are rarely necessary in preseptal and even orbital cellulitis, unless sepsis is
suspected.
White blood cell (WBC) counts tend to be elevated. One study demonstrated an average
WBC count of 14,700 cells/L in patients without bacteremia and 20,400 cells/L in patients
with bacteremia. It is generally believed that the WBC count cannot be used to differentiate
preseptal cellulitis from orbital cellulitis.
Samples of conjunctival discharge, eyelid lesions, and lacrimal sac material should be sent for
culture.
In patients with pain disproportionate to signs and suspected periorbital necrotizing fasciitis,
the laboratory risk indicator for necrotizing fasciitis (LRINEC), particularly markedly
elevated C-reactive protein levels, may be of some utility.[16]

Imaging
Findings on examination that warrant imaging studies include pain on eye movement,
afferent pupillary defect, limited extraocular motions, and resistance on retropulsion.
A computed tomography (CT) scan can delineate the extent of orbital involvement but is not
necessary in all patients with preseptal cellulitis.[17] Orbital ultrasonography can be a useful
tool to help in diagnosing orbital inflammation, although it requires experienced observers
and specialized equipment that may not be available at most institutions. Orbital ultrasound
very rarely, if ever, needed.

Procedures
Consider lumbar puncture in all neonates and in patients with signs or symptoms of
meningitis. Eyelid abscesses should be incised and drained if present.

Histologic findings
Biopsy shows edema and polymorphonuclear leukocytes infiltrating tissue planes.

CT Scanning
A CT scan of the orbit is not necessary for all cases of preseptal cellulitis. For older patients
who clearly have limited infection, conservative management is appropriate. When it is
unclear whether deeper orbital structures are involved (eg, limited ocular motility), a CT scan

is indicated. Consider a CT scan for all children in whom age makes a reliable examination
difficult.
Findings on examination that warrant imaging studies include pain on eye movement,
afferent pupillary defect, limited extraocular motions, resistance on retropulsion, and
arterialization of conjunctival blood vessels.
An appropriate CT scan would include thin axial sections through the orbits and sinuses and
either true coronal sections or coronal reconstructions. A CT scan of the head is also indicated
for any neurologic symptoms or neurologic findings on examination.
CT scan findings in preseptal cellulitis include the following:

Swelling of the eyelid and adjacent preseptal soft tissues

Obliteration of the fat planes or details of the preseptal soft tissues

Absence of orbital inflammation

Staging [18]
A CT scan can delineate the extent of orbital involvement.[17] The modified Chandler staging
system describes a spectrum of disease, as follows:

Stage I - Preseptal cellulitis

Stage II - Inflammatory orbital edema

Stage III - Subperiosteal abscess

Stage IV - Orbital abscess

Stage V - Cavernous sinus thrombosis

Approach Considerations
Earlier diagnosis, expeditious treatment, and improved antibiotics have led to a reduction of
serious ocular and CNS complications in patients with preseptal cellulitis. Treatment involves
management of predisposing conditions, antibiotic therapy, and close observation.[19]
Initial antibiotic therapy is empiric, and, in most cases, a pathogen will not be identified.
Given the predisposing factors, antibiotic choice should be directed toward the organisms that
cause upper respiratory infections, particularly sinusitis. Specific organisms include
Streptococcus pneumoniae, nontypeable H influenzae, and Moraxella catarrhalis. In cases
due to focal trauma, treatment should include coverage for S aureus. Methicillin-resistant S
aureus (MRSA) should be excluded.[20]

The extent of the cutaneous erythema can be outlined with a marking pen or
photodocumented to determine progression or improvement on serial evaluation.

Drainage
Surgical drainage is indicated only for eyelid abscesses[9] and usually is not needed for
uncomplicated preseptal cellulitis. Drainage is also indicated in acute dacryocystitis.

Consultations
Consultation should be considered in cases in which the eye cannot be evaluated or if orbital
spread is suspected. Ophthalmic consultation and evaluation is recommended for all pediatric
patients.[21] Otorhinolaryngology consultation is suggested for medical and surgical treatment
of sinusitis and if fungal infection is suspected. Infectious disease consultation is needed in
all cases not responding to conservative management.

Outpatient care
If an inpatient responds to empiric antibiotics and can be switched to oral antibiotics, further
care can be provided on an outpatient basis. Ambulatory intravenous therapy with daily
review is a possible alternative to inpatient admission in patients with pediatric preseptal
cellulitis.[22]
On outpatient follow-up care, the patient should be evaluated for signs of relapse, including
fever, erythema, edema, pain, and vision loss. If a history of chronic sinusitis is present,
otolaryngology follow-up care should be arranged.

Deterrence
The following treatments can discourage the development of preseptal cellulitis:

Topical antibiotics may prevent traumatic lid lacerations from becoming infected and
causing cellulitis

Adequate treatment of bacterial sinusitis may prevent spread to adjacent tissues

Transfer
Transfer may be required if otorhinologic or ophthalmologic specialties are not available.

Medication Summary
Medications used in the treatment of preseptal cellulitis include the following:

Amoxicillin/clavulanic acid or intramuscular ceftriaxone - Considered for outpatient

treatment in selected patients

Second- or third-generation cephalosporins - Possible choice for initial empiric

therapy

Penicillinase-resistant synthetic penicillin (eg, nafcillin, oxacillin) - If S aureus is

suspected

For patients on IV antibiotics, clinical improvement after 48-72 hours of IV administration

means that a 24-hour trial of oral antibiotics can be employed.

Antibiotics, Other
Class Summary
Antimicrobial therapy must be comprehensive and should cover all likely pathogens in the
context of the clinical setting.
View full drug information

Amoxicillin and clavulanate (Augmentin, Amoclan, Augmentin XR)

Amoxicillin is a third-generation aminopenicillin. Combined with the beta-lactam clavulanic
acid, it is less susceptible to degradation by beta-lactamases produced by microorganisms.
View full drug information

Ceftriaxone (Rocephin)
Ceftriaxone is a third-generation cephalosporin with broad-spectrum, gram-negative activity.
It has lower efficacy against gram-positive organisms and higher efficacy against resistant
organisms. Ceftriaxone arrests bacterial growth by binding to 1 or more penicillin-binding
proteins.

Clindamycin (Cleocin)
Clindamycin is a semisynthetic antibiotic produced by a 7(S)-chloro-substitution of the 7(R)hydroxyl group of the parent compound lincomycin.
View full drug information

Nafcillin
Nafcillin, a second-generation penicillinase penicillin, is used for suspected penicillin Gresistant streptococcal or staphylococcal infections. In severe infections, it should initially be
used parenterally, with a change to oral therapy as the condition warrants.
Due to thrombophlebitis, particularly in elderly persons, administer nafcillin parenterally for
only a short term (1-2d); change to the oral route as clinically indicated.

View full drug information

Cephalexin (Keflex)
Cephalexin is a first-generation cephalosporin that arrests bacterial growth by inhibiting
bacterial cell wall synthesis. It has bactericidal activity against rapidly growing organisms.
Cephalexin's primary activity is against skin flora. Cephalexin is used for skin infections or
prophylaxis in minor procedures.
View full drug information

Oxacillin
Oxacillin is a bactericidal antibiotic that inhibits cell wall synthesis. It is used in the treatment
of infections caused by penicillinase-producing staphylococci. It may be used to initiate
therapy when a staphylococcal infection is suspected.
View full drug information

Cefuroxime (Ceftin, Zinacef)

Cefuroxime is a second-generation oral cephalosporin antibiotic that inhibits cell wall
synthesis and is bactericidal.
Dafpus

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