Preseptal Cellulitis with Conjunctivitis
This presentation—swelling and redness directly below the outer eyebrow with significant conjunctival injection of the upper eye—most likely represents preseptal cellulitis with associated conjunctivitis, requiring prompt treatment with oral antibiotics and close monitoring to prevent progression to orbital cellulitis.
Clinical Assessment
Key Distinguishing Features
- Location matters critically: Swelling below the outer eyebrow (preseptal area) with conjunctival redness suggests infection anterior to the orbital septum, distinct from orbital cellulitis which would present with proptosis, restricted eye movements, and pain with eye movement 1
- The significant redness of the white of the upper eye (bulbar conjunctival injection) indicates concurrent conjunctival involvement, which can occur with preseptal infections 1
- Critical red flags to rule out orbital cellulitis: Check for visual changes, proptosis, restricted or painful eye movements, and pupillary abnormalities—any of these require immediate ophthalmology referral 1
Etiologic Considerations
- Preseptal cellulitis commonly follows local trauma, insect bites, or spread from adjacent sinusitis 1
- The conjunctival injection may represent secondary bacterial conjunctivitis or inflammatory response to adjacent preseptal infection 1
- In severe cases, eyelid swelling and erythema can mimic orbital cellulitis, making careful examination essential 1
Treatment Algorithm
Immediate Management
- Oral antibiotics are required for preseptal cellulitis: Use a broad-spectrum agent covering Staphylococcus aureus and Streptococcus species (including MRSA if risk factors present) 1
- For the conjunctival component with purulent discharge: Add topical broad-spectrum antibiotic drops (e.g., fluoroquinolone) for 5-7 days 1
- If discharge is minimal and presentation suggests viral conjunctivitis component: Supportive care with artificial tears and cold compresses may suffice for the conjunctival aspect 1
Specific Antibiotic Recommendations
- First-line oral therapy: Amoxicillin-clavulanate or cephalexin for typical community-acquired pathogens 1
- If MRSA suspected (recent hospitalization, healthcare exposure, or treatment failure): Trimethoprim-sulfamethoxazole or doxycycline 1
- Duration: 7-10 days minimum, with reassessment at 48-72 hours 1
Adjunctive Measures
- Warm compresses to the affected eyelid area (not hot) applied 3-4 times daily to promote drainage 2
- Eyelid hygiene with diluted baby shampoo or commercial eyelid cleanser if crusting present 2
- Avoid eye rubbing and maintain hand hygiene to prevent spread 1
Critical Monitoring Parameters
48-72 Hour Reassessment
- Worsening or lack of improvement requires immediate ophthalmology referral to rule out orbital extension 1
- Specifically monitor for: development of proptosis, decreased vision, restricted eye movements, or increased pain 1
- Fever, increasing swelling, or systemic symptoms warrant consideration of IV antibiotics and possible imaging 1
Red Flags Requiring Urgent Ophthalmology Consultation
- Any visual loss or decreased vision 1
- Moderate to severe pain (beyond mild discomfort) 1
- Restricted or painful eye movements 1
- Proptosis or globe displacement 1
- Pupillary abnormalities 1
Common Pitfalls to Avoid
- Do not dismiss as simple conjunctivitis when periorbital swelling is present—the combination requires systemic antibiotics 1
- Avoid topical corticosteroids unless under ophthalmology guidance, as they can worsen bacterial infections and mask progression 1
- Do not rely solely on topical antibiotics for preseptal cellulitis—oral systemic therapy is mandatory 1
- Failure to reassess within 48-72 hours can allow progression to sight-threatening orbital cellulitis 1