A 7-year-old girl is brought to the emergency department with a painful swollen eye. She awoke this morning with left eye swelling, which has progressively worsened throughout the day. The patient has seasonal allergies for which she takes an over-the-counter antihistamine. She has no other significant medical history. Temperature is 39.1 C (102.4 F). Examination of the left eye shows tender, swollen, erythematous eyelids and a small abrasion below the eyelid. There is mild conjunctival injection but no drainage. Extraocular movements are normal and do not cause pain. Visual acuity is 20/20 bilaterally. Funduscopic examination is normal, and examination of the right eye is unremarkable. Facial sensation is intact. Which of the following is the most likely diagnosis in this patient?
Preseptal vs orbital cellulitis | ||
Diagnosis | Preseptal cellulitis | Orbital cellulitis |
Clinical features |
|
PLUS
|
Treatment |
|
|
EOM = extraocular movements. | ||
This febrile child has painful eyelid swelling and erythema, findings consistent with preseptal cellulitis. Preseptal cellulitis is an infection located anterior to the orbital septum that most commonly results from a break in the periorbital skin (eg, abrasion, insect bite), allowing cutaneous flora such as Staphylococcus aureus or Streptococcus pyogenes to enter the preseptal space.
Preseptal cellulitis must be differentiated from orbital cellulitis, a more severe infection of the space posterior to the orbital septum that usually results from contiguous spread from another source of infection (eg, sinusitis, dental abscess, preseptal cellulitis). Unlike orbital cellulitis, preseptal cellulitis does not involve intraorbital structures such as orbital fat or the extraocular muscles. Therefore, preseptal cellulitis can be differentiated from orbital cellulitis by the absence of signs indicative of:
As none of these signs are present in this patient, she likely has preseptal rather than orbital cellulitis (Choice F).
Treatment of preseptal cellulitis is typically oral antibiotic therapy with coverage against gram-positive skin flora (eg, clindamycin).
(Choice A) Allergic conjunctivitis generally presents with bilateral conjunctivitis, clear discharge, and ocular itching. Concomitant allergic rhinitis may be present. Periorbital erythema and fever are not seen in allergic conjunctivitis.
(Choice B) Anterior uveitis is inflammation of the anterior chamber of the eye caused by infection or autoimmune disorders (eg, juvenile idiopathic arthritis). Although anterior uveitis can cause eye redness, it typically also causes blurry vision (not seen in this patient) and painful eye movements (not seen in this patient, who has pain due to eyelid swelling).
(Choice C) Bacterial conjunctivitis typically presents with conjunctival injection and purulent discharge. This patient has fever and no discharge.
(Choice D) Cavernous sinus thrombosis is a rare, extraorbital complication of orbital cellulitis with severe ocular symptoms due to the presence of several cranial nerve tracts within the cavernous sinus. Presentation includes headache, ophthalmoplegia, vision loss, and papilledema, none of which are present in this patient.
(Choice E) Optic neuritis is an inflammatory, demyelinating condition most commonly associated with multiple sclerosis. Symptoms include acute vision loss and pupillary defects, not eyelid redness or swelling.
Educational objective:
Preseptal cellulitis is an infection located anterior to the orbital septum. In contrast to orbital cellulitis, preseptal cellulitis does not involve orbital fat or extraocular muscles, and therefore does not cause visual changes, ophthalmoplegia, painful eye movements, or proptosis.