Preseptal cellulitis
Preseptal (periorbital) cellulitis is infection of the eyelid and periorbital soft tissue anterior to the orbital septum, most often from S. aureus or streptococci, confirmed by preserved pain-free eye movements and normal vision that exclude orbital cellulitis. First-line therapy is oral amoxicillin-clavulanate 875/125 mg every 12 hours for 5 to 10 days, with MRSA coverage added for a traumatic portal.
- Topic reviewThe full article, organized the way the exam asks it.
- ABIM-format MCQsVignettes with an explanation for every wrong answer.
- Key factsThe numbers and thresholds worth memorizing, up front.
- AI tutorMedBrain answers the question you're stuck on.
What this article covers
- Overview
Infection anterior to the orbital septum: preseptal (periorbital) cellulitis is infection of the eyelid and periorbital soft tissue anterior to the orbital septum, sparing the orbital fat, extraocular muscles, and globe.
- Epidemiology
More common in children than adults, typically following an upper respiratory or sinus source or minor eyelid trauma.
- Risk factors
Local skin breakdown or trauma near the eyelid: lacerations, insect bites, or other breaks in the periorbital skin allow direct bacterial inoculation and are the trigger for empirically adding MRSA coverage.
- Pathophysiology
Direct inoculation or contiguous extension anterior to the septum: bacteria reach the loose areolar tissue of the eyelid through a break in the skin (trauma, insect bite) or by spread from an…
- Clinical features
Diagnostic pattern: eyelid erythema and edema WITH fully preserved orbital function: the disease is recognized by painful, erythematous, edematous eyelid and periorbital skin together with a…
- Differential diagnosis
Orbital (postseptal) cellulitis: the critical mimic; unlike preseptal disease, it has pain with eye movement, ophthalmoplegia, proptosis, decreased visual acuity, and a relative afferent pupillary defect.
- Diagnosis
This is a clinical diagnosis: established by painful eyelid/periorbital erythema and edema together with a completely normal orbital exam, full pain-free eye movements, no proptosis, and normal…
- Management
First, confirm the diagnosis is truly preseptal: re-verify vision, pupils, and full pain-free eye movements; if any orbital sign is present, manage instead per the orbital-cellulitis pathway (admission, CT imaging, its dosed regimen).
- Complications
Progression to orbital (postseptal) cellulitis: infection tracking across the orbital septum is the principal feared complication, converting a benign eyelid infection into a sight- and life-threatening orbital process.
- Prognosis
Excellent with prompt therapy: preseptal cellulitis rarely leads to serious complications when the eyelid findings are recognized early and the orbital examination is confirmed normal.
- Prevention
Treat local eyelid and periocular infections promptly: manage a hordeolum or chalazion with warm compresses, lid hygiene, and topical antibiotic/steroid ointment, with incision and drainage for…
Read the whole article
Subscribing to Internal Medicine opens every article, the full question bank and MedBrain, on the web, iPhone and Android.
Related articles
- Orbital cellulitis
Orbital cellulitis is infection of the fat and muscle posterior to the orbital septum, most often from spreading sinusitis, that causes proptosis, painful ophthalmoplegia, and vision loss and can progress to cavernous sinus thrombosis. It is a vision- and life-threatening emergency treated with admission, blood and tissue culture, orbital/sinus CT or MRI, and immediate empiric IV vancomycin plus ceftriaxone with ophthalmology and ear, nose, and throat (ENT) involvement.
- Conjunctivitis
Conjunctivitis is inflammation of the conjunctiva from viral, bacterial, or allergic causes presenting with red eye, discharge, and preserved vision, diagnosed clinically by discharge character and managed with supportive care, targeted topical antibiotics, or topical antihistamine/mast-cell-stabilizer therapy.
- Acute rhinosinusitis
Acute rhinosinusitis is inflammation of the nasal cavity and paranasal sinuses lasting up to 4 weeks, presenting with purulent nasal discharge plus nasal obstruction or facial pain/pressure/fullness. Most cases are viral and treated with acetaminophen/ibuprofen plus nasal saline irrigation alone; a minority are bacterial, identified by persistence beyond 10 days, a biphasic worsening course, or severe onset, and treated with amoxicillin-clavulanate 875/125 mg PO every 12 hours for 5 to 7 days.
- Erysipelas
Erysipelas is a superficial bacterial skin infection with prominent dermal lymphatic involvement, almost always caused by group A Streptococcus, producing a painful, sharply demarcated, raised, indurated plaque with a peau d'orange surface. Diagnosis is clinical from the border and depth of involvement, and first-line treatment is oral cephalexin, with intravenous cefazolin for systemic signs and long-term penicillin V for confirmed recurrence.
- Cellulitis
Cellulitis is a nonpurulent, spreading infection of the deep dermis and subcutaneous fat, usually caused by beta-hemolytic streptococci, diagnosed clinically and treated with antibiotics alone since there is no collection to drain.