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
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
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.
• 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.
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