What's the next step for a patient with preseptal cellulitis who develops overnight vision changes and pain with eye movement?

Urgent Imaging for Preseptal Cellulitis with Vision Changes and Pain with Eye Movement

When a patient with preseptal cellulitis develops overnight vision changes and pain with eye movement, urgent CT scan of the orbits with IV contrast is indicated to rule out orbital cellulitis or other complications requiring immediate intervention. 1

Clinical Significance and Differential Diagnosis

The development of vision changes and pain with eye movement in a patient with preseptal cellulitis represents warning signs that strongly suggest progression to orbital cellulitis or other serious complications. These symptoms indicate potential involvement of structures posterior to the orbital septum, which is a medical emergency requiring immediate evaluation and management.

Key differentiating features between preseptal and orbital cellulitis:

• Preseptal cellulitis: Infection limited to tissues anterior to the orbital septum
• Orbital cellulitis: Infection extending posterior to the orbital septum, potentially threatening vision and life

Immediate Management Algorithm

1. Urgent CT orbits with IV contrast

   • First-line imaging modality for suspected orbital cellulitis 1
   • Helps differentiate preseptal from postseptal involvement
   • Can detect abscess formation, foreign bodies, and bone erosion

2. Ophthalmology consultation

   • Should be obtained immediately, even before imaging results are available
   • Warning signs requiring urgent ophthalmology referral include pain with eye movements, movement restriction/diplopia, proptosis, or vision changes 1, 2

3. Consider hospital admission

   • Orbital cellulitis requires hospitalization for intravenous antibiotics 1
   • Multidisciplinary consultation with ophthalmology, otolaryngology, and infectious disease specialists may be necessary

Additional Evaluation

While awaiting imaging and specialist consultation:

• Assess visual acuity in both eyes
• Check pupillary responses (looking for afferent pupillary defect)
• Evaluate extraocular movements
• Check for proptosis
• Assess for red reflex and color vision 2

Common Pitfalls to Avoid

1. Delaying imaging: Vision changes and pain with eye movement are red flags that should prompt immediate imaging rather than continued observation.

2. Starting systemic corticosteroids before ruling out infection: Corticosteroids could potentially worsen an infectious process if used inappropriately.

3. Failing to recognize the urgency: Orbital cellulitis can rapidly progress to vision loss, cavernous sinus thrombosis, and other life-threatening complications if not promptly diagnosed and treated 1.

4. Relying solely on clinical examination: While clinical examination is important, imaging is essential to confirm the diagnosis and guide management when orbital involvement is suspected.

The development of vision changes and pain with eye movement in a patient with preseptal cellulitis represents a potential progression to orbital cellulitis, which requires urgent evaluation and management to prevent serious complications including vision loss and intracranial spread of infection.