PRESEPTAL CELLULITIS

Signs and Symptoms

Preseptal cellulitis is an infection within the eyelid anterior to the orbital septum.1-5 Signs and symptoms include variable pain upon palpation, redness, swelling and red-purple skin coloration that is firm and warm to the touch.1-5 Other ocular signs include conjunctival injection, edema and depending upon the extent and severity of the periorbital processes, corneal insult and in rare instances limited ocular motility.5-7

Eyelid infections involving the orbit and adnexa have been organized via the modified Chandler classification into two forms: the preseptal form (Stage I-Preseptal cellulitis, II-orbital cellulitis, anterior to the orbital septum) and the retroseptal form (Stages III-Subperiosteal abscess, IV-Orbital abscess, V-Cavernous sinus thrombosis) posterior to the orbital septum.8,9 The etiologies of preseptal cellulitis includes untreated hordeolum, dacryocystitis, sinusitis, eyelid trauma and eyelid infection secondary to puncture wound (foreign body, insect bite or sting) and subdermal exposure to the external environment as a result of communication with a sinus following orbital fracture.1-13

The condition is not uncommon and most often occurs as a result of skin infection in children and dacryocystitis in adults.9-12 Microbiologic cultures identify the most common pathogen as Staphylococcus aureus.9-12 There is no predilection for gender, age or region. Immunosuppression may increase the risk.6

Pathophysiology

Preseptal cellulitis begins when inoculating microbes seed infection in the affected region. This can occur secondary to acute dacryocystitis, chronic sinusitis/upper-respiratory infection, puncture wound from a foreign body from blunt or projectile trauma, an insect bite or sting, or as a result of chronic hordeola or chalazia.10,14 Iatrogenic causes include dacryocystorhinostomy, nasolacrimal probing, nasolacrimal stenting, surgical reduction of orbital or eyelid abscess, chalazion and cilia epilation.10,14,15 The most common micro-organisms recovered included Staphylococcus (including methicillin-resistant Staphylococcus aureus-MRSA) and Streptococcus species followed by Haemophilus influenzae and Klebsiella pneumonia.14-17

The vessels of the face and orbit are well connected with an interdigitating vascular web.18-20 The major arcades situated in the eyelids are supplied through branches of the ophthalmic artery (lacrimal, medial palpebral arteries) and from arteries within the face that are part of the external carotid system (infraorbital, zygomatico-facial, transverse facial arteries).18-20 Branches of the ophthalmic system run to the face (supraorbital, supratrochlear and dorsal nasal).18-20

The veins of the eyelid do not form definitive arcades. In fact, they are so vast and variable they are not recognized by specific name.20 These vessels drain the eyelids by way of the superior and inferior ophthalmic veins along with the infraorbital vein, which drains into the cavernous sinus.20

On the nasal aspect of the lids, the angular and facial veins drain inferiorly, forming anastomoses with the inferior ophthalmic and infraorbital veins.20 Directly or indirectly, the orbital venous system is connected to the pterygoid plexus of veins in the face and the vascular system of the nose.21 These systems communicate with the external jugular system. Since there is no valve system restricting the direction of blood flow in the venous system and it is all connected, any infection in the region has access to the cranium.18-20

In order for the eyelids to maintain functional movement, rigid anatomical landmarks must provide shape and stability.21,22 The tarsal plates are found in both the upper and lower lids, extending across the width the globe and maintaining a contoured margin to track with the eye’s curvature.21 The vertical extent of each plate measures 10mm in the superior lid and 5mm in the inferior.21 The tarsal plates are constructed of dense connective tissue into which the eye’s meibomian glands are embedded.21

The muscles that help to elevate the lid are the levator palpebrae superioris and the muscle of Müller. The muscular portion of the levator terminates superiorly in a broad flat tendon known as the levator aproneurosis.21 The tendon runs the entire width of the lid, inserting into the tarsus or the connective tissue that surrounds it.21 There is fibrous connective tissue between the Müller’s muscle and the palpebral conjunctiva creating a natural barrier.22 The pretarsal portion of the orbicularis oculi is situated within the eyelid anterior to the tarsal plates.21

The orbital septum is a connective tissue sheet that forms a barrier between the orbital contents and orbital fat and the eye lid.21 It extends circumferentially around the entire orbital rim inserting into the tarsal plate connective tissue.18,21 The only breaks in the orbital septum occur where vessels and nerves splice through it on their way to anterior structures and where the levator aponeurosis passes through it to insert on the connective tissue of the tarsal plates and dermis.18,21 The anatomy and blood supply of this region make it an ideal habitat for a pocket of infection to proliferate and potentially spread into the orbit, cavernous sinus, blood or brain.1-25

Management

Preseptal cellulitis can be conservatively managed with hot compresses at the site of infection to stimulate the body’s immune repose to the local region as well as broad-spectrum oral antibiotics and oral analgesics.1-17,26-31 When lesions are small, focal, superficial and painful, they can be decompressed and allowed to passively drain by creating an opening with a small-gauge needle, epilating an obstructing eye lash, or opening a visibly blocked gland.30,31 The skin over the lesion can be anesthetized with topical anesthetic to aide in the comfort of the procedure; however, injectable anesthetic is never used as adding additional volume to an already congested region inhibiting diffusion is contraindicated.32

The oral antibiotic classes that are commonly used include the penicillins (cloxacillin, dicloxacillin, flucloxacillin) 250-500mg BID-QID, the cephalosporins (cephalexin, cefadroxil, cephradine) 250-500mg BID-QID, the macrolides (azithromycin as directed on Z-PAK, clarithromycin 500mg BID) and fluoroquinolones (ciprofloxacin, levofloxacin) 500mg BID-QID.26-28 Topical and oral antibiotics should never be tapered and the duration should be 7-10 days depending upon the severity of the infection or the area involved.

In more severe cases or cases with a larger area of infection, intravenous antibiotics can be initiated. In cases of concurrent dacryocystitis, epiphora may result, leading to a lateral canthus fissure or other ulcerative defects secondary to the drying effects of the sodium laden tears.33 In these cases, a topical antibiotic ointment can augment a skin moisturizer to protect against infection and aid in lesion resolution.

Clinical Pearls

Visualization with computed tomography (CT) or magnetic resonance imaging (MRI) may be required to understand the extent of larger infections.

In cases where abscess is present, surgical excision may be required.

In cases involving the nasolacrimal system, even after the infection has resolved, probing may be required to assay the system for patency. In many instances, nasolacrimal system stenting and dacryocystorhinostomy must be completed to reestablish complete communication and function.

Any time the primary treatment fails, a culture and sensitivity along with additional testing for organisms such as methicillin-resistant Staphylococcus and fungi must be considered.34

If a lesion opens, it is not unreasonable, while a flow is established, to remove all of the mucopurulent discharge possible. These lesions may be susceptible to topical antibiotics, which should be included in the regimen. Since they will continue to drain, they should be kept clean and covered.

Given the risk of infection spread, patients should not be instructed to massage an infected area or compress an infected area with the goal of expression.

1. Starska K, Lukomski M, Starska-Dawidowskda D. Preseptal orbital abscess as a post-traumatic late complication–review of the literature and case report. Otolaryngol Pol. 2007;61(3):331-4.

2. Benton J, Karkanevatos A. Preseptal cellulitis due to Mycobacterium marinum. J Laryngol Otol. 2007;121(6):606-8.

3. Wong AC, Mak ST. Preseptal cellulitis in a child caused by Megacopta centrosignatum. J AAPOS. 2012;16(6):577-8.

4. Brugha RE, Abrahamson E. Ambulatory intravenous antibiotic therapy for children with preseptal cellulitis. Pediatr Emerg Care. 2012;28(3):226-8.

5. Pandian DG, Babu RK, Chaitra A, et al. Nine years’ review on preseptal and orbital cellulitis and emergence of community-acquired methicillin-resistant Staphylococus aureus in a tertiary hospital in India. Indian J Ophthalmol. 2011; 59(6): 431-435.

6. Im SK, Yoon KC. Corneal perforation with preseptal cellulitis in a patient with acute lymphocytic leukemia. J Korean Med Sci. 2010;25(8):1251-2.

7. Schielke KC, Hilton AJ, Brown R. Acquired Brown’s syndrome associated with preseptal cellulitis. Strabismus. 2008;16(3):95-6.

8. Uzcátegui N, Warman R, Smith A, et al. Clinical practice guidelines for the management of orbital cellulitis. J Pediatr Ophthalmol Strabismus. 1998;35(2):73-9.

9. Chandler JR, Langenbrunner DJ, Stevens ER. The pathogenesis of orbital complications in acute sinusitis. Laryngoscope. 1970;80(9):1414-28.

10. Liu IT, Kao SC, Wang AG, et al. Preseptal and orbital cellulitis: a 10-year review of hospitalized patients. J Chin Med Assoc. 2006;69(9):415-22.

11. Bagheri A, Tavakoli M, Aletaha M, et al. Orbital and preseptal cellulitis: a 10-year survey of hospitalized patients in a tertiary eye hospital in Iran. Int Ophthalmol. 2012;32(4):361-7.

12. Babar TF, Zaman M, Khan MN, Khan MD. Risk factors of preseptal and orbital cellulitis. J Coll Physicians Surg Pak. 2009;19(1):39-42.

13. Sivori LA 2nd, de Leeuw R, Morgan I, Cunningham LL Jr. Complications of frontal sinus fractures with emphasis on chronic craniofacial pain and its treatment: a review of 43 cases. J Oral Maxillofac Surg. 2010;68(9):2041-6.

14. Chaudhry IA, Shamsi FA, Elzaridi E, et al. Inpatient preseptal cellulitis: experience from a tertiary eye care centre. Br J Ophthalmol. 2008;92(10):1337-41.

15. Elmann S, Pointdujour R, Blaydon S, et al. Periocular abscesses following brow epilation. Ophthal Plast Reconstr Surg. 2012;28(6):434-7.

16. Jackson K, Baker SR. Periorbital cellulitis. Head Neck Surg. 1987;9(4):227-34.

17. Bababeygy SR, Silva RA, Sun Y, Jain A. Rifampin and linezolid in the treatment of methicillin-resistant Staphylococcus aureus preseptal cellulitis. Ophthal Plast Reconstr Surg. 2009;25(3):227-8.

18. Snell RS, Lemp MA. The orbital blood vessels. In: Snell RS, Lemp MA. Clinical anatomy of the eye, 2nd Ed. Blackwell Science Inc.;1998:277-93.

19. Oyster CW. The orbit. In: Oyster CW. The human eye structure and function. Cinaur Associates Inc.;1999: 111-31.

20. Oyster CW. Blood supply and drainage. In: Oyster CW. The human eye structure and function. Cinaur Associates Inc.;1999:247-89.

21. Oyster CW. The eyelids and lacrimal system. In: Oyster CW. The human eye structure and function. Cinaur Associates Inc.;1999:291-320.

22. Kakizaki H, Zako M, Nakano T, et al. Fibrous connective tissue between Müller’s muscle and the palpebral conjunctiva as a reinforcement structure and a natural barrier for the upper eyelid. Okajimas Folia Anat Jpn;82(3):79-82.

23. Kakizaki H, Takahashi Y, Nakano T, et al. Whitnall ligament anatomy revisited. Clin Experiment Ophthalmol. 2011;39(2):152-5.

24. Gentry LR. Anatomy of the orbit. Neuroimaging Clin N Am. 1998;8(1):171-94.

25. Turvey TA, Golden BA. Orbital anatomy for the surgeon. Oral Maxillofac Surg Clin North Am. 2012;24(4):525-36.

26. Mandal R, Banerjee AR, Biswas MC, et al. Clinicobacteriological study of chronic dacryocystitis in adults. J Indian Med Assoc. 2008;106(5):296-8.

27. Ahrens-Palumbo MJ, Ballen PH. Primary dacryocystitis causing orbital cellulitis. Ann Ophthalmol. 1982;14(6):600-1.

28. Durán-Giménez-Rico MC, Boto-de-los-Bueis A, Alberto MJ, et al. Preseptal and orbital cellulitis in childhood: response to intravenous antibiotics. Arch Soc Esp Oftalmol. 2005;80(9):511-6.

29. Goawalla A, Lee V. A prospective randomized treatment study comparing three treatment options for chalazia: triamcinolone acetonide injections, incision and curettage and treatment with hot compresses. Clin Experiment Ophthalmol. 2007;35(8):706-12.

30. Lindsley K, Nichols JJ, Dickersin K. Interventions for acute internal hordeolum. Cochrane Database Syst Rev. 2010;(9):CD007742.

31. Panicharoen C, Hirunwiwatkul P. Current pattern treatment of hordeolum by ophthalmologists in Thailand. J Med Assoc Thai. 2011;94(6):721-4.

32. Ogle OE, Mahjoubi G. Local anesthesia: agents, techniques, and complications. Dent Clin North Am. 2012;56(1):133-48.

33. Deangelis D, Hurwitz J, Mazzulli T. The role of bacteriologic infection in the etiology of nasolacrimal duct obstruction. Can J Ophthalmol. 2001;36:134–39.

34. Velazquez AJ, Goldstein MH, Driebe WT. Preseptal cellulitis caused by trichophyton (ringworm). Cornea. 2002;21(3):312-4.