Preseptal and Orbital Cellulitis: What You Need to Know

Preseptal and orbital cellulitis are infrequent infectious illnesses that require an early diagnosis to avoid complications.

Reviewed and approved by the dermatologist Maria del Carmen Hernandez.

Written by Maria del Carmen Hernandez

Last update: 22 December, 2021

Preseptal and orbital cellulitis are rare infections, but with the potential to develop significant health complications in children.

For this reason, it’s essential that they be diagnosed early in order to start their therapy as soon as possible and prevent progress towards more serious stages. Next, we’ll tell you everything you need to know about them.

What are preseptal cellulitis and orbital cellulitis?

Cellulite is the inflammation of the subcutaneous cellular tissue. Both the preseptal and orbital (or septal) types are characterized by affecting the periocular and ocular tissues, respectively.

According to a publication of the Spanish Society of Out-of-hospital Pediatrics and Primary Care, preseptal and orbital cellulitis occur with a higher prevalence in pediatric age. Although they’re different entities, they’re similar in some signs such as inflammation of the eyelid.

The causative pathogens of these infections vary according to the age of the child. In general, Staphylococcus aureus and Streptococcus pyogenes enter these areas from trauma, while Streptococcus pneumoniae appears after respiratory illness (for example, after sinusitis).

Preseptal cellulitis

This infection affects the soft tissues of the periorbital and superficial areas of the eyelid, but without affecting the orbit or the eyeball. It’s much more common than orbital cellulitis and even its prognosis is usually more favorable.

However, timely diagnosis and early treatment are key, as the infection can advance towards the orbit and complicate the clinical picture.

In general, it’s caused by the spread of some infections of the eyelids (such as styes or chalazion), by foreign body trauma, or insect bites.

Orbital cellulitis

In orbital cellulitis, the inflammatory process is located behind the orbital septum and can affect the soft tissues of the eye (muscles and fatty tissue). This condition is an emergency, and without proper treatment, it can cause severe consequences on the child’s vision.

In general, it’s caused by the spread of infections in the paranasal sinuses (sinusitis) or other diseases of the respiratory tract.

Clinical manifestations

In most cases, the clinical manifestations of preseptal cellulitis are as follows:

• Edema of the eyelid of one eye
• Inflammation and redness of the tissues around the eye
• Pain upon palpation, but not when mobilizing the eye

On the contrary, orbital cellulitis has distinctive characteristics and a more pronounced symptomatology:

• Painful eye movements
• Bulging of the eyeball (proptosis)
• High fever
• General discomfort
• Difficulty moving the eyeball (ophthalmoplegia)
• Double vision (diplopia)

Complications of preseptal and orbital cellulitis

Preseptal cellulitis is usually benign, has a good prognosis, and improves after five to seven days of correct antibiotic treatment.

On the other hand, orbital cellulitis can cause important consequences in the vision and a serious deterioration of health in general. Among the most prominent complications, we can list the following:

• Ischemic optic neuropathy caused by increased intraorbital pressure
• Cavernous sinus thrombosis
• Sepsis
• Intracranial abscess
• Meningitis
• Orbital and subperiosteal abscess

The treatment options for preseptal cellulitis and orbital cellulitis

While there are important advances in antimicrobial therapies and diagnostic tools, treating orbital cellulitis can be challenging. Because of this, rapid diagnosis and early initiation of therapy are essential in order to avoid complications and improve results.

Oral antibiotics

Although the medical treatment of these infections is based on the use of antibiotics, the predisposing factors, such as sinusitis, must also be treated.

Faced with mild preseptal cellulitis in children older than 1 year, treatment with broad-spectrum antibiotics is oral and outpatient.

Intravenous medication

Those patients who don’t respond favorably or whose symptoms worsen despite oral medication should begin intravenous antibiotic treatment. This option even works when resistant germs are suspected.

In the event that the initial diagnosis is orbital cellulitis, intravenous antibiotics should be started immediately in all cases.

Surgical intervention

Preseptal cellulitis doesn’t usually require surgical intervention, except in cases of eyelid abscess or foreign body trauma. In these cases, surgical drainage along with debridement is the most appropriate option.

The importance of early cellulite management

Preseptal cellulitis and orbital cellulitis are considered ophthalmological emergencies, which must be diagnosed and treated early to avoid the most serious complications.

Although preseptal cellulitis tends to manifest itself in a milder form, it must be treated just as promptly as orbital cellulitis to limit its evolution.