Physical Examination Findings of Preseptal Cellulitis
Preseptal cellulitis presents with characteristic physical examination findings confined to the eyelids and soft tissues anterior to the orbital septum, including eyelid erythema, edema, warmth, and tenderness without affecting extraocular movements or vision. 1
Key Physical Examination Findings
Cardinal Signs
- Eyelid erythema (redness)
- Eyelid edema (swelling)
- Eyelid warmth
- Eyelid tenderness/pain
- Skin surface may appear dimpled like an orange peel (peau d'orange) 1
Important Negative Findings (Distinguishing from Orbital Cellulitis)
- Normal extraocular movements (absence of ophthalmoplegia)
- Absence of proptosis (forward displacement of the eye)
- Absence of diplopia (double vision)
- Normal visual acuity 2
Associated Findings
- Possible periorbital vesicles or bullae
- Potential cutaneous hemorrhage (petechiae or ecchymoses)
- Possible lymphangitis and regional lymph node inflammation 1
- Chemosis (conjunctival edema) may be present in some cases 3
Systemic Manifestations
- Usually mild systemic symptoms
- Fever may be present (in approximately 51.5% of cases) 2
- Occasionally tachycardia, confusion, or leukocytosis 1
Laboratory Findings
- C-reactive protein (CRP) levels typically lower than in orbital cellulitis
- Median CRP in preseptal cellulitis: 17.85 mg/L
- A CRP >120 mg/L suggests orbital rather than preseptal involvement 2
Diagnostic Pearls
Key Differentiating Features from Orbital Cellulitis
- Preseptal cellulitis affects only tissues anterior to the orbital septum
- Orbital cellulitis involves tissues posterior to the orbital septum
- Preseptal cellulitis typically occurs in younger children (mean age 3.9 years vs. 7.5 years for orbital cellulitis) 2
- Preexisting sinusitis is rare in preseptal cellulitis (2%) but common in orbital cellulitis (77.8%) 2
Common Causes
- Skin trauma/recent surgery (27.8%)
- Acute dacryocystitis (32.6%)
- Sinusitis/upper respiratory infection (28.8%)
- Skin infections including impetigo 3
- Varicella zoster infection can occasionally cause preseptal cellulitis 4
Imaging Considerations
- Imaging is not routinely required for typical preseptal cellulitis
- CT orbits with IV contrast is indicated when:
- Clinical findings are insufficient to distinguish from orbital cellulitis
- Poor response to initial therapy
- Suspicion of abscess formation or deeper infection 1
Common Pitfalls
- Misdiagnosing orbital cellulitis as preseptal cellulitis can lead to vision-threatening complications
- Clinical findings alone may not be specific enough to distinguish preseptal from orbital infections in all cases 1
- Puffy eyelids may indicate early preseptal cellulitis, which requires prompt treatment to prevent progression 1
- Warning signs requiring urgent ophthalmology referral: pain with eye movements, movement restriction/diplopia, proptosis, or vision changes 1
By carefully assessing these physical examination findings, clinicians can accurately diagnose preseptal cellulitis and distinguish it from the more serious orbital cellulitis, ensuring appropriate and timely treatment.