What is the difference between preseptal cellulitis and a stye (hordeolum)?

Distinguishing Preseptal Cellulitis from Stye (Hordeolum)

Preseptal cellulitis is a diffuse infection of the eyelid and periorbital soft tissues anterior to the orbital septum presenting with widespread erythema, edema, warmth, and tenderness, while a stye (hordeolum) is a well-localized, painful nodule at the eyelid margin caused by infection of an eyelash follicle or associated gland. 1, 2

Key Clinical Distinctions

Location and Distribution

• Preseptal cellulitis involves diffuse swelling and erythema affecting the entire eyelid and surrounding periorbital tissues, with warmth and tenderness extending across a broad area 1
• Stye (hordeolum) presents as a discrete, localized nodule or pustule specifically at the eyelid margin, typically pointing toward either the skin surface (external hordeolum) or conjunctival surface (internal hordeolum) 2

Physical Examination Findings

• Preseptal cellulitis demonstrates:

  • Diffuse periorbital erythema and edema without clear borders 1
  • Warmth across the affected eyelid and periorbital tissues 1
  • Tenderness throughout the swollen area 1
  • Absence of proptosis, normal extraocular movements, and preserved vision (distinguishing it from orbital cellulitis) 1, 3

• Stye demonstrates:

  • A well-circumscribed, tender nodule at the lid margin 2
  • Localized induration and erythema limited to the immediate area of the abscess 4
  • Often visible purulent material or pointing at the eyelid margin 2

Etiology and Pathogenesis

• Preseptal cellulitis typically results from percutaneous introduction of pathogens through skin breaks, trauma, or odontogenic spread, with causative organisms being Gram-positive bacteria (particularly Staphylococcus aureus and streptococci) 1, 5
• Stye is caused by bacterial infection (usually S. aureus) of an eyelash follicle (external hordeolum) or meibomian gland (internal hordeolum), representing a simple localized abscess 4, 2

Treatment Approach Differences

Preseptal Cellulitis Management

• Outpatient treatment with high-dose oral amoxicillin-clavulanate for mild cases without systemic signs, with mandatory reassessment within 24-48 hours 3
• Hospitalization required if eyelid >50% closed, systemic signs present, or inability to adequately examine the eye 3
• Broad-spectrum antibiotics targeting Gram-positive pathogens (IV amoxicillin-clavulanate, cefazolin, or ceftriaxone for severe cases) 3
• Consider MRSA coverage if penetrating trauma, purulent drainage, or known MRSA colonization 3

Stye Management

• Incision and drainage is the primary treatment for simple abscesses like styes 4
• Antibiotics are NOT needed for simple styes where induration and erythema are limited to the defined area of the abscess 4
• Warm compresses to promote spontaneous drainage 2

Critical Pitfalls to Avoid

Misdiagnosis Risk

• Do not assume all periorbital infections are preseptal cellulitis, as this can delay diagnosis of orbital cellulitis, which requires urgent intervention 1
• Assess for proptosis, impaired extraocular movements, decreased visual acuity, or ophthalmoplegia—any of these indicate orbital involvement requiring immediate imaging 1, 3

Imaging Considerations

• Preseptal cellulitis: Most cases are diagnosed clinically without imaging, but obtain CT orbits with IV contrast if clinical findings cannot reliably distinguish from orbital cellulitis, if there are signs of orbital involvement, or if no improvement after 24-48 hours of antibiotics 1, 6, 3
• Stye: No imaging required for straightforward cases 2

Inappropriate Antibiotic Use

• Do not prescribe antibiotics for simple styes—this represents unnecessary antibiotic exposure when drainage alone is curative 4
• Do not delay antibiotics for preseptal cellulitis—prompt treatment prevents progression to vision-threatening orbital cellulitis 3, 7

Risk Factors for Progression (Preseptal Cellulitis)

Monitor for these features indicating higher risk of progression to orbital cellulitis:

• High neutrophil count 1
• Absence of infectious conjunctivitis 1
• Gross periorbital edema 1
• Age >3 years 1
• Previous antibiotic therapy without improvement 1