To review the clinical features and etiology of
To review management of the patient with
suspected preseptal cellulitis, focusing on differentiation from orbital
To review the concepts of “level of evidence”
and “strength of recommendation”
A 4 year old male child is brought to your office by his mother who notes that his right eyelids seem red and swollen for the past 24 hours. She says that the child was outside playing in the backyard yesterday, and thinks he was stung by a bee over the right upper eyelid. The redness and swelling began soonafter. Although the child is in some discomfort, he seems otherwise well and is afebrile. On examination there is mild-moderate edema of the upper and lower eyelids but no apparent proptosis. Visual acuity is 20/20 bilaterally with normal extraocular movements, pupillary responses, and IOPs.
Which of the following is the most likely diagnosis?
• Orbital cellulitis
Orbital cellulitis should be in the differential diagnosis for a patient presenting with a red swollen eyelid. However, in the case described the absence of such features as proptosis, chemosis, ophthalmoplegia, decreased visual acuity, and systemic symptoms make preseptal cellulitis more likely.
• Necrotizing fasciitis
Necrotizing fasciitis is a potentially devastating soft tissue infection that has the potential to spread rapidly and cause significant morbidity and mortality. It is commonly caused by Group A Streptococcus pyogenes. Occasionally, necrotizing fasciitis can affect the eyelids. Features suggestive of necrotizing fasciitis include rapidly advancing infection, pain of proportion to clinical exam, necrosis, and purulent discharge.
• Preseptal cellulitis
• Paranasal sinusitis
Paranasal sinusitis can be a cause of orbital cellulitis, however sinusitis alone cannot account for the case described.
Preseptal cellulitis (also called periorbital cellulitis or anterior orbital cellulitis) is an inflammation or infection of soft tissue anterior to the orbital septum. It occurs primarily in children, and although relatively benign it presents a challenge to clinicians in that it must be differentiated from the more sinister orbital cellulitis, an infection posterior to the orbital septum.