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Preseptal Cellulitis

Prepared by: Junior Intern Charles Nicole P. Alonzo

Cellulitis
is a skin infection (inflammation) characterized with redness., swelling, pain and warmth.

Preseptal type (or Periorbital)


also known as eyelid cellulitis, is a medical condition that occurs around the eyelid

Preseptal cellulitis
is a periocular superficial cellulitis that has not breached the orbital septum

Periorbital Cellulitis Findings: Inflammation and swelling of soft tissues anterior to, but not posterior to the orbital septum, consistent with periorbital cellulitis.

Pathophysiology
This may also arise in one of three situations:
As a result of local skin trauma such as lacerations and insect bites Due to spread from local infection such as dacrocystitis, hordeolum and paranasal sinuses Spread from distant infections such as those outlined above as well as from the upper respiratory tract.

The most common pathogenic organisms are


S. aureus, S. epidermidis, streptococci anaerobes

MRSA has also been isolated in cases but again, this currently remains very rare

Symptoms
Unilateral Tenderness, erythema and swelling of lids and periorbital area May be a mild fever

Often recent history of sinusitis/local skin abrasions or bites

Signs
Erythema with tense edema: may not be able to open lid Tenderness Normal or just slightly blurred visual acuity

Signs
Absence of
Proptosis
Restriction in ocular motility Pain on eye movement

Evidence of optic neuropathy

Differential Diagnosis Orbital/Preseptal Cellulitis


Necrotising fasciitis Chalazion Allergic lid swelling Severe viral conjunctivitis Cavernous sinus thrombosis Erysipelas Other orbital conditions e.g. thyroid eye disease, orbital tumours/pseudotumours, orbital vasculitis Other conditions e.g. insect bite, angioedema, maxillary osteomyelitis

Staging
Orbital infections fall into one of five categories:
Stage I - preseptal cellulitis Stage II - orbital cellulitis Stage III - subperiosteal abscess (which may arise from orbital cellulitis or paranasal sinusitis) Stage IV - orbital abscess (a complication of orbital cellulitis) Stage V - cavernous sinus thrombosis and infection (the cavernous sinus drains venous blood from both eyes)

Management
Adults: 250(qds) - 500(tds)mg oral co-amoxiclav depending on severity of infection, for 10 days with daily review until there is definite improvement (then every 2-7 days until complete recovery). Children: 20-40mg/kg/day oral co-amoxiclav over 24h in three divided doses. Lid abscesses should be drained.

Hospital management may involve intravenous therapy (1-2gm iv ceftriaxone daily until response is seen)

Complications
Progression to stage II and beyond of orbital infections. Unusually, lagophthalmos, lid abscess, cicatricial ectropion and lid necrosis may also be seen in these patients.

Prognosis
Prompt diagnosis and treatment should result in an uncomplicated course and full recovery

Prevention
Prophylactic antibiotics are prudent in the management of surgical and accidental trauma to the lid. Chloramphenicol ointment is a good first choice, applied qds to the clean wound for a week. Traumatic lid laceration also benefits from a review a 48-72h down the line to help identify any emerging preseptal cellulitis early.

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