Complications of Preseptal Cellulitis
The most serious complication of preseptal cellulitis is progression to orbital cellulitis, which can lead to vision loss, intracranial infection, and potentially death if not treated promptly and appropriately. 1
Common Complications of Preseptal Cellulitis
Progression to Orbital (Postseptal) Cellulitis
- Occurs when infection breaches the orbital septum and enters the orbital space
- Characterized by:
Subperiosteal Abscess Formation
- Collection of purulent material between the periorbital bone and periosteum
- Most commonly occurs in the medial orbital wall (58.8% of cases) 3
- May require surgical drainage if not responsive to antibiotics
Orbital Abscess
- Collection of purulent material within the orbital tissues
- Requires prompt surgical intervention to prevent vision loss 1
Intracranial Complications
- Epidural or subdural abscess
- Brain abscess
- Venous thrombosis (including cavernous sinus thrombosis)
- Meningitis 1
Vascular Complications
- Cavernous sinus thrombosis - a rare but life-threatening complication
- Characterized by bilateral eye involvement, severe headache, altered mental status 1
Risk Factors for Complications
- Delayed or inadequate treatment
- Young age (children under 5 years are at higher risk) 4
- Sinusitis as the underlying cause (particularly ethmoid sinusitis) 1, 3
- High C-reactive protein levels (CRP >120 mg/L suggests orbital involvement) 3
- Immunocompromised status
Warning Signs of Progression to Complications
- Fever (present in 82.2% of orbital cellulitis cases vs 51.5% in preseptal) 3
- Worsening symptoms despite 24-48 hours of appropriate antibiotic therapy 1
- Development of proptosis, impaired visual acuity, or impaired/painful extraocular mobility 1
- Altered mental status or severe headache (suggests intracranial involvement) 1
- Significantly elevated inflammatory markers (CRP >120 mg/L) 3
Diagnostic Approach for Suspected Complications
Contrast-enhanced CT scan of the paranasal sinuses and orbits is indicated when:
MRI with contrast is preferred when:
- Intracranial complications are suspected
- More detailed assessment of soft tissue involvement is needed 1
Management of Complications
Hospitalization for intravenous antibiotics when:
- Progression to orbital cellulitis is suspected
- Patient does not improve within 24-48 hours of outpatient treatment
- Infection is progressive 1
Surgical intervention is indicated for:
- Subperiosteal or orbital abscess formation
- Inadequate response to medical therapy
- Evidence of bone erosion on imaging 1
Multidisciplinary consultation with:
- Ophthalmology
- Otolaryngology
- Infectious disease specialists
- Neurosurgery (for intracranial complications) 1
Prognosis
Despite the potential for serious complications, early diagnosis and prompt treatment with appropriate antibiotics and/or surgical intervention typically results in good outcomes with minimal long-term sequelae 4. However, delayed diagnosis or inadequate treatment of complications can lead to permanent vision loss, neurological deficits, or even death 1.
Clinical Pearls and Pitfalls
- Misdiagnosing orbital cellulitis as preseptal cellulitis is a dangerous pitfall that can lead to vision-threatening complications 2
- Blood cultures have extremely low yield in preseptal cellulitis and are not routinely recommended 4
- Cultures from eye swabs and local abscesses provide the highest positive yield for identifying pathogens 4
- Staphylococcus aureus is the most commonly isolated pathogen in preseptal cellulitis 4
- Daily follow-up is essential for patients with preseptal cellulitis treated as outpatients until definite improvement is noted 1