- Christopher Gappy, MD
Christopher Gappy, MD
- Clinical Instructor
- University of Michigan, Department of Ophthalmology and Visual Sciences
- Steven M Archer, MD
Steven M Archer, MD
- University of Michigan, Department of Ophthalmology and Visual Sciences
- Michael Barza, MD
Michael Barza, MD
- Professor of Medicine
- Tufts University School of Medicine
- Section Editors
- Stephen B Calderwood, MD
Stephen B Calderwood, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — Bacterial Infections
- Professor of Medicine (Microbiology and Immunobiology)
- Harvard Medical School
- Jonathan Trobe, MD
Jonathan Trobe, MD
- Section Editor — Ophthalmology
- Professor of Ophthalmology and Visual Sciences
- Professor of Neurology
- University of Michigan Kellogg Eye Center
- Morven S Edwards, MD
Morven S Edwards, MD
- Section Editor — Pediatric Infectious Diseases
- Professor of Pediatrics
- Baylor College of Medicine
Preseptal cellulitis (sometimes called periorbital cellulitis) is an infection of the anterior portion of the eyelid, not involving the orbit or other ocular structures. In contrast, orbital cellulitis is an infection involving the contents of the orbit (fat and ocular muscles) but not the globe. Although preseptal and orbital cellulitis may be confused with one another because both can cause ocular pain and eyelid swelling and erythema, they have very different clinical implications. Preseptal cellulitis is generally a mild condition that rarely leads to serious complications, whereas orbital cellulitis may cause loss of vision and even loss of life. Orbital cellulitis can usually be distinguished from preseptal cellulitis by its clinical features (ophthalmoplegia, pain with eye movements, and proptosis) and by imaging studies. In cases in which the distinction is not clear, clinicians should treat patients as though they have orbital cellulitis. Both conditions are more common in children than in adults, and preseptal cellulitis is much more common than orbital cellulitis.
The pathogenesis, microbiology, clinical manifestations, diagnosis, and treatment of preseptal cellulitis will be reviewed here. Orbital cellulitis and its complications, such as subperiosteal abscess and orbital abscess, are discussed separately. Orbital infections caused by fungi, mainly the Mucorales (which cause mucormycosis) and Aspergillus spp and, much more rarely, Mycobacterium tuberculosis, are also presented elsewhere. (See "Orbital cellulitis" and "Mucormycosis (zygomycosis)" and "Epidemiology and clinical manifestations of invasive aspergillosis" and "Tuberculosis and the eye".)
Preseptal cellulitis and orbital cellulitis involve different anatomic sites, with preseptal cellulitis referring to infections of the soft tissues anterior to the orbital septum and orbital cellulitis referring to infections posterior to it (figure 1). Neither infection involves the globe. (See 'Anatomy' below.)
There is some debate regarding the appropriate terminology for these infections. Some clinicians use the term "periorbital cellulitis" rather than "preseptal cellulitis" or use the terms interchangeably. We prefer the term "preseptal cellulitis" to make a clear distinction between this infection and the more serious infection, "orbital cellulitis." Orbital cellulitis is sometimes referred to as "postseptal cellulitis"; we favor the term "orbital cellulitis," and will use it throughout this topic.
Basic familiarity with the anatomy of the eye is fundamental to understanding the pathogenesis, clinical manifestations, and complications of preseptal and orbital cellulitis. The orbit is a cone-shaped structure, lying horizontally, with its apex in the skull. It is surrounded by paranasal sinuses, namely, the frontal (lying superior), ethmoid (medial) and maxillary (inferior) sinuses (figure 2). The orbit is lined by periosteum. The ethmoid sinuses are separated from the orbit by a paper-thin layer called the lamina papyracea, which contains many perforations for nerves and blood vessels as well as some natural fenestrations termed Zuckerkandl's dehiscences. The most common route of infection of the orbit is by extension from the ethmoid sinuses, presumably through these perforations.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Zhang J, Stringer MD. Ophthalmic and facial veins are not valveless. Clin Exp Ophthalmol 2010; 38:502.
- Ambati BK, Ambati J, Azar N, et al. Periorbital and orbital cellulitis before and after the advent of Haemophilus influenzae type B vaccination. Ophthalmology 2000; 107:1450.
- Botting AM, McIntosh D, Mahadevan M. Paediatric pre- and post-septal peri-orbital infections are different diseases. A retrospective review of 262 cases. Int J Pediatr Otorhinolaryngol 2008; 72:377.
- Mills RP, Kartush JM. Orbital wall thickness and the spread of infection from the paranasal sinuses. Clin Otolaryngol Allied Sci 1985; 10:209.
- Jackson K, Baker SR. Periorbital cellulitis. Head Neck Surg 1987; 9:227.
- Ganesh A, Venugopalan P. Preseptal orbital cellulitis following oral trauma. J Pediatr Ophthalmol Strabismus 2000; 37:315.
- Smith TF, O'Day D, Wright PF. Clinical implications of preseptal (periorbital) cellulitis in childhood. Pediatrics 1978; 62:1006.
- Hutcheson KA, Magbalon M. Periocular abscess and cellulitis from Pasteurella multocida in a healthy child. Am J Ophthalmol 1999; 128:514.
- Chaudhry IA, Shamsi FA, Elzaridi E, et al. Inpatient preseptal cellulitis: experience from a tertiary eye care centre. Br J Ophthalmol 2008; 92:1337.
- Charalampidou S, Connell P, Fennell J, et al. Preseptal cellulitis caused by community acquired methicillin resistant Staphylococcus aureus (CAMRSA). Br J Ophthalmol 2007; 91:1723.
- Blomquist PH. Methicillin-resistant Staphylococcus aureus infections of the eye and orbit (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc 2006; 104:322.
- Moran GJ, Krishnadasan A, Gorwitz RJ, et al. Methicillin-resistant S. aureus infections among patients in the emergency department. N Engl J Med 2006; 355:666.
- Miller J. Acinetobacter as a causative agent in preseptal cellulitis. Optometry 2005; 76:176.
- Mathews D, Mathews JP, Kwartz J, Inkster C. Preseptal cellulitis caused by Acinetobacter lwoffi. Indian J Ophthalmol 2005; 53:213.
- Brannan PA, Kersten RC, Hudak DT, et al. Primary Nocardia brasiliensis of the eyelid. Am J Ophthalmol 2004; 138:498.
- Caça I, Cakmak SS, Unlü K, et al. Cutaneous anthrax on eyelids. Jpn J Ophthalmol 2004; 48:268.
- Milstone AM, Ruff AJ, Yeamans C, Higman MA. Pseudomonas aeruginosa pre-septal cellulitis and bacteremia in a pediatric oncology patient. Pediatr Blood Cancer 2005; 45:353; discussion 354.
- Raja NS, Singh NN. Bilateral orbital cellulitis due to Neisseria gonorrhoeae and Staphylococcus aureus: a previously unreported case. J Med Microbiol 2005; 54:609.
- Sears JM, Gabriel HM, Veith J. Preseptal cellulitis secondary to Proteus species: a case report and review. J Am Optom Assoc 1999; 70:661.
- Raina UK, Jain S, Monga S, et al. Tubercular preseptal cellulitis in children: a presenting feature of underlying systemic tuberculosis. Ophthalmology 2004; 111:291.
- Velazquez AJ, Goldstein MH, Driebe WT. Preseptal cellulitis caused by trichophyton (ringworm). Cornea 2002; 21:312.
- Seltz LB, Smith J, Durairaj VD, et al. Microbiology and antibiotic management of orbital cellulitis. Pediatrics 2011; 127:e566.
- Nageswaran S, Woods CR, Benjamin DK Jr, et al. Orbital cellulitis in children. Pediatr Infect Dis J 2006; 25:695.
- Durand, ML. Periocular infections. In: Principles and Practice of Infectious Diseases, 7th ed, Mandell, GL, Bennett, JE, Dolin, R (Eds), Churchill Livingstone Elsevier, Philadelphia 2010. p.1569.
- Sobol SE, Marchand J, Tewfik TL, et al. Orbital complications of sinusitis in children. J Otolaryngol 2002; 31:131.
- Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 2011; 52:e18.
- Howe L, Jones NS. Guidelines for the management of periorbital cellulitis/abscess. Clin Otolaryngol Allied Sci 2004; 29:725.
- Uzcátegui N, Warman R, Smith A, Howard CW. Clinical practice guidelines for the management of orbital cellulitis. J Pediatr Ophthalmol Strabismus 1998; 35:73.
- Sorin A, April MM, Ward RF. Recurrent periorbital cellulitis: an unusual clinical entity. Otolaryngol Head Neck Surg 2006; 134:153.
- Karkos PD, Karagama Y, Karkanevatos A, Srinivasan V. Recurrent periorbital cellulitis in a child. A random event or an underlying anatomical abnormality? Int J Pediatr Otorhinolaryngol 2004; 68:1529.
- CLINICAL MANIFESTATIONS
- DIFFERENTIAL DIAGNOSIS
- Clinical evaluation and diagnosis
- Laboratory testing
- Imaging studies
- Antibiotic regimens
- Response to therapy
- Recurrent preseptal cellulitis
- SUMMARY AND RECOMMENDATIONS