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Preseptal, orbital cellulitis require different treatment regimens
Large well-defined abscesses, as in this case, should be surgically drained.
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A 15-year-old female presented to the emergency department with a swollen left upper eyelid. The patient admitted to picking at a pimple the week prior, and the lid became increasingly swollen over time, with an exponential increase in swelling over the previous 24 hours.
When the patient presented to the emergency department (ED) she was barely able to open her left eye. The eyelid was tender, red and warm to touch.
An ophthalmic consult was requested by the physician on duty. Prior to our arrival, a computed tomography (CT) scan with intravenous contrast was obtained. The patient had a temperature of 98.2° Fahrenheit. A complete blood count showed slightly elevated leukocytes.
The patient’s visual acuities were 20/20 at 10 feet in the right eye and 20/30 at 10 feet in the left eye. Pupils were equal, round and reactive to light with no relative afferent pupillary defect. The extraocular muscles had full range of motion without pain in each eye. The cornea was clear, the conjunctiva was not injected and there was no drainage from the eye itself.
The patient denied any previous episodes of eyelid inflammation. She indicated that in the recent past she had a similar abscess on her foot, which she drained on her own. This healed on its own without complications. She had never had a comprehensive eye examination. She denied any recent sinus infection, fever, flu or dental procedures. The patient had no known medication allergies. She was not taking any medication.
Diagnosis, treatment
Knutson R
The patient was diagnosed with preseptal cellulitis of the left upper eyelid with a focal eyelid abscess. Prior to our arrival at the ED, intravenous ceftriaxone was administered. The CT scan showed a focal enhancing lesion of fluid collection in the superior and lateral subcutaneous tissue adjacent to, but separated from, the globe. The lesion measured 25 mm by 11 mm by 18 mm. There were no fractures and no sinus involvement. There was no postseptal involvement.
We incised and drained the abscess while the patient was under procedural sedation. Local anesthetic was not used. A horizontal incision was made using a number 11 scalpel, and blood and pus were drained from the abscess. The suppurative material was collected and sent to the microbiology laboratory for Gram stain and culture. Bacitracin ophthalmic ointment was applied to the wound, which was left open to facilitate additional drainage and allow healing by secondary intention.
The patient was started on a course of oral amoxicillin-clavulanate 500 mg-125 mg twice per day. She was instructed to continue the oral antibiotic for 10 days, use bacitracin ophthalmic ointment on the eyelid three times per day and take ibuprofen if necessary for pain. Warm compresses were recommended four times per day to facilitate drainage. The patient was instructed to follow up at our eye clinic 2 days later.
Follow-up
At the follow-up appointment, the patient’s eyelid was considerably less swollen, and her eye was able to open more fully. The wound had not yet scabbed over but it was no longer draining. The results of the culture indicated methicillin-resistant Staphylococcus aureus (MRSA) and that the patient was insensitive to penicillins. However, given that she had already improved, she was maintained on oral amoxicillin-clavulanate for the full 10-day course.
This decision was supported by guidelines for treatment of preseptal cellulitis with MRSA. If a resistant strain is present and does not respond to initial treatment with amoxicillin-clavulanate, the patient should be switched to a drug with activity against MRSA, such as doxycycline, trimethoprim-sulfamethoxazole, clindamycin or an intravenous antibiotic if the infection is more severe. Because the patient in this case responded to treatment with amoxicillin-clavulanate, that therapy was continued.
The culture also indicated that the infectious organism was sensitive to the topical bacitracin ophthalmic ointment. The ointment was also continued. It is worth noting that, because MRSA has become highly prevalent in skin infections, the most recent guidelines for the treatment of preseptal cellulitis recommend using an agent that is effective against MRSA as the first line of treatment.
The patient returned for a second follow-up appointment 4 days later. At this time, a scab had formed, and the lid was no longer swollen. The patient was instructed not to pick the scab and continue using bacitracin ophthalmic ointment until the scab resolved. She was also instructed to complete the full 10-day course of oral amoxicillin-clavulanate.
Anatomy, pathophysiology
The orbital septum extends from the periosteum of the frontal bone and inserts into the tarsal plate of the eyelid. This fibrous tissue prevents infection from entering the orbit, where it would have access to the brain.
Preseptal (or periorbital) cellulitis is an infection of the eyelid tissues located anterior to the orbital septum. In contrast, orbital (or postseptal) cellulitis is an infection of orbital tissue, located posterior to the orbital septum. Preseptal cellulitis may progress to orbital cellulitis if there is a break in the orbital septum.
Etiology
Preseptal cellulitis may be caused by a hordeolum or chalazion, acute dacryocystitis, trauma, extraocular skin infections, sinusitis, respiratory infections or ear infections. Orbital cellulitis may be caused by sinusitis, trauma or systemic infections or caused iatrogenically during surgery. It can also be caused by spread of periorbital infections involving the face, globe, lacrimal sac or teeth. The orbital plate of the ethmoid bone, which is paper thin (lamina papyracea), is often implicated in orbital cellulitis, as it can allow passage of infection through the thin ethmoid bone to the orbit.
Common pathogens involved in both conditions include Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, Streptococcus pyogenes, Pseudomonas aeruginosa, herpes simplex or herpes zoster.
Making the diagnosis
A patient with preseptal or orbital cellulitis presents with a tender, red, swollen eyelid and surrounding area. The eyelid may be so swollen that the patient cannot open the eye. If the infection is preseptal, the eye will not be proptotic, there will be no restriction of the extraocular muscles, and the patient will have no pain with eye movements. The pupils should respond normally with no afferent pupillary defect. There is usually no or minimal conjunctival injection. Often, an external cause is observable in preseptal cellulitis.
In contrast, a patient with orbital cellulitis will have pain with eye movements, restriction of the extraocular muscles and proptosis. In addition, conjunctival injection and chemosis are usually seen. The patient may have strabismus and subsequent diplopia due to the restriction of extraocular muscle movement. In severe cases, the patient may have optic neuropathy with a relative afferent pupillary defect. The patient will often have a fever and related illness.
To differentiate between preseptal and orbital cellulitis, the patient must be questioned about recent illness, sinus infection, surgery or dental work. If orbital cellulitis is suspected, a CT scan of the orbit and sinuses is indicated. The CT scan may reveal sinusitis or abscess formation. Without obtaining a CT scan, the clinician may be able to differentiate preseptal cellulitis by feeling loculation with palpation. A complete blood count can be helpful to determine if a widespread infection exists. Open wounds and drainage from wounds should be cultured.
Typical treatment regimen
Preseptal cellulitis is treated with oral antibiotics. Traditionally, amoxicillin-clavulanate has been commonly used as a first-line treatment. Third-generation cephalosporins, such as cefpodoxime and cefdinir, are also commonly used. If the patient is allergic to penicillin, trimethoprim-sulfamethoxazole or moxifloxacin can be used. If MRSA is suspected, trimethoprim-sulfamethoxazole, doxycycline or clindamycin should be prescribed.
Current guidelines recommend using an agent effective against MRSA as the first-line treatment, due to the high prevalence of MRSA in preseptal cellulitis cases. However, neither doxycycline nor trimethoprim-sulfamethoxazole are effective against some strains of streptococcal infections, and doxycycline should not be used in children. Therefore, the current recommendation is either to prescribe clindamycin alone or trimethoprim-sulfamethoxazole in addition to either amoxicillin-clavulanate, cefpodoxime or cefdinir.
Severe preseptal cellulitis cases or suspected orbital cellulitis cases usually require hospitalization with intravenous antibiotics. The patient should be followed daily until improvement is seen and then at regular short intervals until resolved.
Orbital cellulitis is treated with broad-spectrum intravenous antibiotics, and the patient should be admitted to the hospital. Agents may include ampicillin-sulbactam, piperacillin-tazobactam, ceftriaxone, moxifloxacin or metronidazole. If MRSA is suspected, trimethoprim-sulfamethoxazole, tetracyclines, vancomycin or clindamycin may be used.
The patient should be re-evaluated multiple times daily while admitted to the hospital. When the orbital cellulitis has shown a measurable improvement, oral antibiotics may be initiated, and intravenous antibiotics discontinued.
Large well-defined abscesses, as the patient in our case had, should be surgically drained. Sinus surgery and drainage may be required if there is sinus involvement. In any situation, if no improvement is seen in the patient’s condition within 1 to 2 days, a repeat CT scan and complete blood count are indicated.
- References:
- Clark WN. Paediatr Child Health. 2004;9(7):471-472.
- Gappy C, Archer S, Barza M. Preseptal cellulitis. UpToDate Website. http://www.uptodate.com/contents/preseptal-cellulitis. Updated December 21, 2015. Accessed April 11, 2016.
- Givner, LB. Pediatr Infect Dis J. 2002;21(12):1157-1158.
- Holdeman NR. Preseptal cellulitis/orbital cellulitis. In: Onofrey BE, Skorin L, Holdeman NR, eds. Ocular Therapeutics Handbook. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011:178-184.
- Preseptal cellulitis, Orbital cellulitis. In: Gerstenblith AT, Rabinowitz MP, eds. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:146-149;159-162.
- For more information:
- Rachel Knutson, BA, plans on graduating from Pacific University this year. She can be reached at wats1217@pacificu.edu.
- Leonid Skorin Jr., OD, DO, MS, FAAO, FAOCO, practices at the Mayo Clinic Health System in Albert Lea, Minn., and is a member of the Primary Care Optometry News Editorial Board. He can be reached at Mayo Clinic Health System; skorin.leonid@mayo.edu.
Disclosures: Knutson and Skorin report no relevant financial disclosures.