A 4-year-old boy is brought to your office by his mother who notes that his right eyelids seem red and swollen for the past 24 hours. She says that the child was outside playing in the backyard yesterday, and thinks he was stung by a bee over the right upper eyelid. The redness and swelling began soon thereafter. Although the child is in some discomfort, he seems otherwise well and is afebrile. On examination there is mild-moderate edema of the upper and lower eyelids but no apparent proptosis. Visual acuity is 20/20 bilaterally with normal extraocular movements, pupillary responses, and IOPs. Color vision was normal.
- To review the clinical features and etiology of preseptal cellulitis
- To review management of the patient with suspected preseptal cellulitis, focusing on differentiation from orbital cellulitis
Quick Question: Which of the following is the most likely diagnosis?
Orbital cellulitis should be in the differential diagnosis for a patient presenting with a red swollen eyelid. However, the lack of classic features of this condition — proptosis, chemosis, ophthalmoplegia, decreased visual acuity, and systemic symptoms make orbital cellulitis unlikely.
Necrotizing fasciitis is a potentially devastating soft tissue infection that has the potential to spread rapidly and cause significant morbidity and mortality. It is commonly caused by Group A Streptococcus pyogenes. Occasionally, necrotizing fasciitis can affect the eyelids. Features suggestive of necrotizing fasciitis including rapidly advancing infection, pain of proportion to clinical exam, necrosis, and purulent discharge are not present here.
Paranasal sinusitis can be a cause of orbital cellulitis, however sinusitis alone cannot account for the case described.
Preseptal cellulitis (also called periorbital cellulitis or anterior orbital cellulitis) is an inflammation or infection of soft tissue anterior to the orbital septum. It occurs primarily in children, and although relatively benign, it presents a challenge to clinicians in that it must be differentiated from the more sinister orbital cellulitis, an infection posterior to the orbital septum.
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