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Getting an eyeful of preseptal cellulitis.

Practitioners are often confronted with the mildly to moderately ill child who presents with an area of distinct redness and/or swelling of the skin around the eyelid. This is often accompanied by purulent conjunctival discharge, fever, purulent rhinorrhea, or concomitant acute otitis media. You must then decide whether this is preseptal cellulitis (peri-orbital cellulitis), orbital cellulitis, an allergic reaction, erythema secondary to trauma, contact dermatitis, or the result of eye rubbing. You must also perform a thorough physical examination, particularly evaluating the child’s level of toxicity, and the tympanic membranes, pharynx, lungs, and skin. Preseptal cellulitis (PC) is an infection of the skin surrounding the eyelid that is localized anterior to the orbital septum — a thin layer of fascia that provides a barrier to deeper invasion by infectious agents. The typical signs of PC are erythema, edema, and pain of the eyelid(s). It is usually unilateral, and may be associated with fever and acute otitis media (AOM). Specific manage ment options are addressed in the following cases. PC must be differentiated from the very serious infection, orbital cellulitis, which usually involves an osteomyelitis and invasion of the orbital bones. The cardinal features of orbital cellulitis are proptosis, chemosis, olphthalmoplegia, visual loss, and restricted ocular mobility. Immediate hospitalization, computed tomography (CT) scan of the orbit, and ophthalmologic referral is essential. Rarely, the swelling of the skin around the eyelid in PC may be so severe that a complete examination of the globe for signs of orbital cellulitis may be difficult or impossible, thus requiring CT imaging of the globe (similar to Figure 1).