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Distinguishing Orbital Cellulitis From Preseptal Cellulitis.

CHARLESTON, S.C. -- Orbital cellulitis and preseptal cellulitis may look alike, but the management approaches to the two are quite different, Dr. Amy K. Hutchinson said at a pediatric meeting sponsored by the Medical University of South Carolina.

Orbital cellulitis, an infection of the eye's orbit involving tissues posterior to the orbital septum, is a dangerous infection that requires hospitalization and intravenous antibiotics. In contrast, the more common preseptal cellulitis is usually a milder infection and can often be managed on an outpatient basis.

Preseptal cellulitis is also known as "periorbital cellulitis," but "I don't like that term because it doesn't really tell you what you're dealing with," said Dr. Hutchinson, a pediatric ophthalmologist at the university's Storm Eye Institute in Charleston.

In the preantibiotic era, 20% of children who developed orbital cellulitis died of complications such as meningitis or brain abscess. Another 20% were left blind in the affected eye.

Orbital cellulitis can arise from paranasal sinusitis; trauma to the eye; a retained foreign body in the orbit; ocular surgery; or contagious spread of infection from adjacent structures, such as dacryocystitis, dental abscesses, or preseptal cellulitis. Ethmoid sinusitis is the most common etiology, she noted.

The most frequent causative bacteria are Staphylococcus aureus, S. pyogenes, and Streptococcus pneumoniae. Haemophilus inftuenzae is no longer a major player because of H. influenzae type b vaccination, she said.

Preseptal cellulitis is much more common than orbital cellulitis in children. It can arise from trauma, an external ocular infection, or lymphatic spread of infection via the upper respiratory tract or middle ear.

The two conditions can look quite similar. Edema and erythema of the lids are seen in both, as are fever and leukocytosis. Examination of the eye itself is key. If the eye has normal motility, no proptosis, and no pupillary signs and the child has normal vision, the diagnosis is preseptal cellulitis. "It may look terrible, but under the lid they see normally," Dr. Hutchinson said.

In contrast, patients with orbital cellulitis have limited ocular motility; distinct proptosis; and, in severe cases, decreased vision and/or pupillary signs. Orbital computerized tomography may show ethmoid sinusitis, soft-tissue swelling, and sometimes a subperiosteal or orbital abscess, she said.

Management of orbital cellulitis requires hospitalization and broad-spectrum intravenous antibiotics as well as a nasal decongestant, an antihistamine, and humidification to help decompress the sinuses. Frequent monitoring of vision, motility, and proptosis along with doing pupillary eye exams are essential. Surgical drainage is not mandatory if clinical signs improve within 48 hours, Dr. Hutchinson said.

Surgery is necessary if there is no clinical improvement within 48 hours; the condition worsens, especially if there is decreased vision and relative afferent pupillary defect; or there is a frank orbital, nor subperiosteal, abscess. Surgical drainage of the abscess should be combined with sinus drainage.

Preseptal cellulitis often can be treated on an outpatient basis with an oral antibiotic such as Augmentin, although more severely ill patients and very young children still require hospitalization and intravenous antibiotics. Either way, patients need to be followed up daily during healing for signs of orbital cellulitis.
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Comment:Distinguishing Orbital Cellulitis From Preseptal Cellulitis.
Publication:Family Practice News
Geographic Code:1USA
Date:Feb 15, 2000
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