What is the clinical presentation of preseptal cellulitis?

Clinical Presentation of Preseptal Cellulitis

Preseptal cellulitis presents with eyelid and periorbital erythema, swelling, tenderness, and warmth limited to tissues anterior to the orbital septum, without affecting eye movement, vision, or causing proptosis. 1

Key Clinical Features

Preseptal cellulitis (also called inflammatory edema) is characterized by:

• Local signs:

  • Eyelid erythema and edema
  • Periorbital swelling (present in 72.4% of cases) 2
  • Tenderness and warmth of affected area
  • Skin surface may have "orange peel" appearance (peau d'orange) due to superficial cutaneous edema 3
  • Possible vesicles, bullae, or cutaneous hemorrhage (petechiae/ecchymoses) 3

• Systemic manifestations (usually mild):

  • Fever (present in 51.5% of preseptal cellulitis cases) 4
  • Possible tachycardia, leukocytosis 3

Distinguishing from Orbital Cellulitis

The critical distinction between preseptal and orbital cellulitis lies in the following features that are absent in preseptal cellulitis but present in orbital cellulitis:

• Pain with eye movements
• Restricted eye movement (ophthalmoplegia)
• Diplopia
• Proptosis
• Vision changes 1, 4

Laboratory Findings

• C-reactive protein (CRP) levels are typically lower in preseptal cellulitis compared to orbital cellulitis
  • Median CRP in preseptal cellulitis: 17.85 mg/L (IQR 6.33-50.10)
  • A CRP >120 mg/L suggests orbital rather than preseptal involvement 4

Common Predisposing Factors

• In children: Skin lesions 5
• In adults: Dacryocystitis 5
• Localized trauma
• Upper respiratory tract infections
• Bacteremia (especially in young children) 1
• Sinusitis (present in only 2% of preseptal cellulitis cases versus 77.8% of orbital cellulitis) 4

Microbiology

The most common pathogens in preseptal cellulitis include:

• Streptococcus species (most common according to IDSA) 1
• Staphylococcus aureus 1, 5
• Streptococcus pyogenes
• Streptococcus pneumoniae 1

Age Distribution

• More common in children than adults
• Mean age of presentation in pediatric studies: approximately 62 months (5 years) 2
• Significantly younger age at presentation compared to orbital cellulitis (3.9 years vs. 7.5 years) 4

Clinical Pitfalls

1. Misdiagnosis risk: Failing to distinguish between preseptal and orbital cellulitis can lead to inappropriate management and potential complications.

2. Warning signs requiring urgent ophthalmology referral:

   • Development of pain with eye movements
   • Movement restriction/diplopia
   • Proptosis
   • Vision changes
   • Worsening symptoms despite 24-48 hours of antibiotic therapy 1

3. Complications: Though less common than with orbital cellulitis, preseptal cellulitis can progress to orbital cellulitis, bacteremia, and rarely meningitis if inadequately treated 1

4. Special populations: Immunocompromised patients may develop severe complications from preseptal cellulitis, including toxic shock syndrome in rare cases 6

Prompt recognition and appropriate treatment of preseptal cellulitis is essential to prevent progression to more serious orbital involvement and potential complications.