The Baby With a Swollen Eyelid

Humberto Salazar; Madhuri Chilakapati, MD; Kimberly G. Yen, MD

Disclosures

November 19, 2018

Diagnosis and Treatment Strategies

The diagnosis of preseptal cellulitis is largely based on history, physical examination, and ophthalmologic evaluation. The most common clinical manifestations of preseptal cellulitis are eyelid swelling, pain, and erythema.[1,6,10] A history of recent dacryocystitis, upper respiratory infection, local trauma, or insect bite are suggestive of the diagnosis. Purulent discharge and fever sometimes occur as well.

Orbital cellulitis presents with the same clinical manifestations as preseptal cellulitis. The key differentiating findings in orbital cellulitis, caused by inflammation and displacement of the orbital contents, include pain with eye movements, chemosis, proptosis, decreased visual acuity, and ophthalmoplegia with diplopia.[1,2] Fever can occur in both conditions, but one study found that it is twice as frequent in orbital cellulitis than in preseptal cellulitis.[10] Furthermore, it is very uncommon for either condition to spread into the globe and cause endophthalmitis.

In cases in which the diagnosis is unclear or there is suspicion of orbital cellulitis, contrast-enhanced CT of the orbits and sinuses is used to differentiate from preseptal cellulitis. Indications for imaging include signs suggestive of orbital cellulitis; concern about central nervous system involvement; lack of improvement with appropriate therapy after 24-48 hours; and difficulty with examination, such as in young children and patients with significant edema.[12]

Because blood cultures are rarely positive and cultures from the infection site are difficult to obtain, medical treatment for preseptal cellulitis is commonly empirical. Antibiotic therapy should be initiated quickly, and drug selection should account for the most common infecting organisms (S aureus, S pyogenes, other streptococci and anaerobes), including emerging drug-resistant bacteria.[12,13] Common antibiotic regimens include clindamycin alone or trimethoprim-sulfamethoxazole plus amoxicillin, cefpodoxime, or cefdinir. Local susceptibility trends in each institution should be used to guide antibiotic therapy in patients with preseptal cellulitis.

In adults with mild preseptal cellulitis, as well as in children older than 1 year, outpatient treatment with a 7- to 10-day course of oral antibiotics may be initiated with close follow-up. If there is no response within 24-48 hours, therapy should be switched to intravenous antibiotics, and the patient should be monitored for the development of orbital cellulitis.[12] Children younger than 1 year, immunosuppressed patients, and those with evidence of toxicity or more severe infection should be admitted to the hospital for administration of intravenous antibiotics, similar to the medical treatment of orbital cellulitis.[12] Once clinical improvement is noted, treatment can be switched to outpatient oral antibiotics as previously described.

Preseptal cellulitis typically responds rapidly to appropriate antibiotic therapy and rarely recurs. Recurrent preseptal cellulitis is typically secondary to an underlying cause that has not been diagnosed or treated.[14]

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