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   Table of Contents      
ORIGINAL ARTICLE
Year : 1996  |  Volume : 44  |  Issue : 4  |  Page : 225-227

Pre-septal cellulitis - Varied clinical presentations


Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry, India

Correspondence Address:
Vasudev Anand Rao
Department of Ophthalmology, JIPMER, Pondicherry-605 006
India
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Source of Support: None, Conflict of Interest: None


PMID: 9251267

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  Abstract 

Preseptal cellulitis has a typically benign course when treated with antibiotics, the clinical course depending on age of the patient, aetiology and the causative organism. In this study, 14 cases of preseptal cellulitis are documented with the age ranging from 2 to 55 years. The organisms isolated were Staphylococcus aureus (7 cases), Streptococcus pyogenes (2 cases) and Pseudomonas aeruginosa (1 case). In the remaining four patients no organism could be identified. All except four patients were cured within 6 weeks. Complications seen included lagophthalmos, lid abscess, cicatricial ectropion and lid necrosis in one patient each. The prognosis for preseptal cellulitis is good with appropriate antibiotics and surgical therapy.

Keywords: Lid, preseptal cellulitis, infection, ulceration, necrosis.


How to cite this article:
Rao VA, Hans R, Mehra AK. Pre-septal cellulitis - Varied clinical presentations. Indian J Ophthalmol 1996;44:225-7

How to cite this URL:
Rao VA, Hans R, Mehra AK. Pre-septal cellulitis - Varied clinical presentations. Indian J Ophthalmol [serial online] 1996 [cited 2019 Aug 23];44:225-7. Available from: http://www.ijo.in/text.asp?1996/44/4/225/24565



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Preseptal cellulitis is an infection anterior to the orbital septum, characterised by acute onset of lid oedema, tenderness, erythema, warmth and chemosis. It may be associated with pyrexia and leucocytosis. The visual acuity, eye movements and intraocular pressure (IOP) are normal as the eye ball is not involved. On the other hand, post septal cellulitis is more likely to cause proptosis associated with restricted mobility of the globe, chemosis and toxic systemic symptoms.[1]

Conditions such as ethmoiditis in children, stye, impetigo, dacryocystitis, tooth abscess and lid trauma may precede preseptal cellulitis. It has also been reported in the debilitated, alcoholic patients and after insect bites.[2][3][4] Staphylococcus aureus, Streptococcus pyogenes, Haemophilus influenzae and Streptococcus pneumoniae are most frequently implicated in the causation of preseptal cellulitis. It has a benign course if treatment is given with appropriate combination of antibiotic. However, it may progress to orbital cellulitis, abscess formation and intracranial complications like meningitis.[3]


  Materials and methods Top


Fourteen patients with the diagnosis of preseptal cellulitis were hospitalised and followed in our department. The patients with corneal involvement were excluded. Patient evaluation included general physical examination, ocular examination, clinical photography at the time of admission and after the recovery of the patient. The investigations also included microscopic evaluation of the pus using Gram's stain. The swab was taken from the site of infection, ulceration, lid margin and conjunctival sac. This was immediately sent for culture and sensitivity. The blood culture samples were taken in case the patient had pyrexia. Skull X-ray and para nasal sinus (PNS) views were taken in all the cases. All the patients were given intravenous gentamicin 3 mg/kg/day eight hourly. The renal function tests were done at the time of admission and repeated every three days. Ten of these patients were started on intravenous penicillin G 400,000 to 800,000 i.u. Qid and another four on intravenous 500 mg Qid.

All the patients were also gives non-steroidal anti-inflammatory drugs and local dressing with sofratulle gauze where ulceration developed. In patients with a pointing lid abscess, incision and drainage was done under local anaesthesia.


  Results Top


Results are summarized in the Table. The age of the 14 patients in this series ranged between 2 to 55 years. Eight were males and 6 females. Preceding the onset of illness, 4 patients had impetigo in the upperlid and forehead region, one had hordeolum externum and 2 had penetrating injury of the upper lid with thorn. Three patients had a history of recurrent upper respiratory tract infection (all of them were below 5 years). One patient had dacryocystitis in the affected side (55 years old). Four patients did not have any clinically detectable predisposing factor Table.

The otolaryngological examination and X-ray PNS showed evidence of ethmoidal and maxillary sinusitis in 7 patients. The causative organisms were isolated in 10 patients and the commonest organism was Staphylococcus aureus. Based on the culture and sensitivity report, 3 patients were switched over to cloxacillin-gentamicin regimen. The blood culture results did not show any growth. One 48 year old male patient (case 13) with the history of thorn injury, developed lid necrosis which healed following antibiotic treatment [Figure - 1] [Figure - 2] and later required skin grafting. Three patients developed late complications within 3 to 6 months. One had subacute lid abscess which was drained, followed by a good response; the second patient developed marked lid scarring and cicatricial ectropion, while the third patient had a severe lagophthalmos due to scar formation.


  Discussion Top


Preseptal cellulitis typically has a benign clinical course when appropriate antibiotic treatment is given. However, in some cases, it may lead to complications such as lid abscess and orbital cellulitis.[3],[4]

During the clinical evaluation of cases of preseptal cellulitis, one must look for the possible source of infection.[4],[5] Two of our cases had thorn injury, four had impetigo, one had chronic dacryocystitis and the other one had a hordeolum externum.

Investigations for preseptal cellulitis typically include complete blood counts, blood culture and Gram's staining of discharge with culture and sensitivity of the pus obtaioned from the site of the lesion Contrary to previous studies, we did not find positive blood culture results in our patients. However, none of our patients had severe systemic illness or bacteraemia.

In our study we did not find organisms on Gram's stain of the discharge from the lesion. Therefore, broad spectrum antibiotic coverage was given. Intravenous penicillin G was given in children who were less than 10 years of age. In this age group, sinusitis and upper respiratory tract infection (which is generally associated with preseptal cellulitis) has usually been reported to be caused by Haemophilus influenzae and Streptococcus pneumoniae. The culture-sensitivity test showed Staphylococcus sensitive to cloxacillin in three of the above patients. Following this, the antibiotic was changed to cloxacillin from penicillin G.

Necrosis of eyelid is uncommon due to good vascularity of the lids. However, the local oedema and the enzymes released by the growing β-hemolytic Streptococci impair the blood supply of the lid and hence gangrene could develop.[6][7][8][9] Only one of our patients developed necrosis of the lids. There was no contributory factor for the development of lid necrosis as described by previous authors.[5],[10] Surgical intervention with skin grafting is indicated in case of larger defects and failure of granulation formation.[5],[10] Only one patient in our study needed skin grafting.

On the basis of this experience, we recommend that after treatment of preseptal cellulitis with systemic antibiotics, the patients should be followed up for possible late complications.

 
  References Top

1.
Weiss A, Froemdu D, Eglin K, et al: Bacterial periorbital and orbital cellulitis in childhood. Ophthalmology. 90:195-203, 1983.  Back to cited text no. 1
    
2.
Mortads A. Post-operative gangrene of eye lid. Br J Ophthalmol. 48:114-117, 1964.  Back to cited text no. 2
    
3.
Duke-Elder S. The Ocular Adnexa. System of Ophthalmology, Vol.13. London, Henry Kimpton. 1974, pp 91-93.  Back to cited text no. 3
    
4.
Zeligowski AA, Peled IJ, Wexler MR. Eye lid necrosis after spider bite. Am J Ophthalmol. 101:254-255, 1986.  Back to cited text no. 4
    
5.
Lawrence Stone MD, Francois C, Sun Ae Ma. Streptococcal lid necrosis in previously healthy children. Can J Ophthalmol. 26:386-390, 1991.  Back to cited text no. 5
    
6.
Collins RN, Nadel MD. Gangrene due to the haemolytic streptococcus - A rare but treatable disease. N Engl. J Med. 272:578-580, 1965.  Back to cited text no. 6
    
7.
Walters RA. Fatal case of necrotising fasciitis of the eyelid. Br J Ophthalmol. 72:428-431, 1988.  Back to cited text no. 7
    
8.
Prendiville KJ, Bath PE. Lateral cantholysis and eyelid necrosis secondary to Pseudomonas aeruginosa. Ann Ophthalmol. 20:193-195, 1988.  Back to cited text no. 8
    
9.
Ross J, Kohlhepp PA. Gangrene of eyelids. Ann Ophthalmol. 5:84-87, 1973.  Back to cited text no. 9
    
10.
Hornblass A, Herschorn BJ, Stern K, et al. Orbital abscess. Surv Ophthalmol. 29:169-178, 1984.  Back to cited text no. 10
    


    Figures

  [Figure - 1], [Figure - 2]
 
 
    Tables

  [Table - 1]



 

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