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Researchers Identify Common Causes, Late Complications Of Preseptal ...

October 03, 2008

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Sinusitis, upper-respiratory infection, acute dacryocystitis, and a recent history of trauma or surgery appear to be the most common causes of preseptal cellulitis, a study found.

While most patients respond favorably to systemic antibiotics, patients may experience late complications that require surgical intervention, the authors said.

Imtiaz A. Chaudhry, MD, PhD, FACS, and colleagues retrospectively reviewed medical records obtained for 104 patients who had presented with preseptal cellulitis positioned anteriorly to the orbital septum between January 1991 and December 2005. The study results were published in the October issue of British Journal of Ophthalmology.

Follow-up averaged 3.2 years.

The investigators found that preseptal cellulitis had been caused by acute dacryocystitis in 32.6% of patients, upper-respiratory infection or sinusitis in 28.8% of patients, and trauma or recent surgery in 27.8% of patients.

Half of the patients required surgery; of these patients, 74% underwent dacryocystorhinostomy with probing and stenting, and 28.8% underwent abscess or chalazion drainage.

Among the 40 patients (38.5%) who had surgical intervention and cultures were performed, 36 (90%) were positive; Staphylococcus and Streptococcus species were the most frequent micro-organisms, followed by Haemophilus influenzae and Klebsiella pneumoniae.

The investigators identified positive blood cultures in two of the 34 patients in whom blood was drawn.

Late complications included subacute lid abscesses, eyelid necrosis and cicatricial ectropion.

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10-year-old Girl Presents With Eye Swelling - Healio

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A previously healthy 10-year-old female presents to your office with some painful swelling with erythema about the left eye. Although she was previously healthy, a detailed review of her past medical history revealed that she had been diagnosed with left-sided lacrimal duct stenosis as an infant, which spontaneously resolved by 1 year of age but still periodically recurs. It manifested as excessive tearing for a few days to weeks at a time. Since it never bothered her, it was never pursued. She denies any injury or past episodes of pain or erythema. She otherwise feels well and has had no sick contacts, including anyone with "pink eye." Her immunizations are up to date.

On examination, her vital signs are normal, and the only abnormal finding is that about the left eye, with some painful swelling and diffuse erythema surrounding the eye, as shown in Figures 1 and 2. There also appears to be additional discrete swelling just inferior to the medial canthus, with a dark spot from which a small amount of material drained. Upon further questioning, the patient admitted to picking at the area, resulting in the small scab before the more diffuse redness and swelling occurred. The rest of her facial and ocular exam was normal.

Figure 1. Infraorbital swelling with erythema. Source: James H. Brien, DO.

Figure 2. Infraorbital swelling with erythema and a dark spot medial and inferior to the medial canthus. Source: James H. Brien, DO.

What's your diagnosis?

A. Preseptal cellulitisB. Dacryocystitis with secondary cellulitisC. DacryoadenitisD. Choices A and B

Answer and discussion:

The correct answer is both preseptal cellulitis and acute dacryocystitis (choice D). Preseptal cellulitis is simply a descriptive term meaning inflammation or an infection that is contained to the anterior portion of the orbital septum, a membrane that separates the orbital contents from the outer structures (Figure 3). It may be due to the spread of a sinus infection, injury, hematogenous seeding of the area or, as in this case, spread beyond an infection within the lacrimal sac, likely with the help of picking at the spot. When due to the latter, the responsible organism is usually Staphylococcus aureus or a streptococcal species, but it can be mixed. The typical finding is swelling in the area of the lacrimal sac, just medial and inferior to the medial canthus. There may be a history of mucopurulent material occasionally getting into the eye by retrograde movement. An abscess can develop, which may get large enough to result in spontaneous drainage, but this is unlikely.

Figure 3. The orbital septum in blue. Source: The Medical Gallery of Mikael Häggerström.

Figure 4. Needle drainage. Source: James H. Brien, DO

Management is almost always left to an ophthalmologist, especially if any drainage is to be attempted (Figure 4). However, medical management may be all that is needed. Warm compresses may be tried, along with an oral anti-staph/anti-strep antimicrobial. If there is any material that can easily be expressed, it should be cultured. However, firm pressure should be avoided, as the anatomic structures are fairly delicate and can be damaged. In recurrent cases, even with successful medical management, referral to an ophthalmologist is always recommended for more definitive management.

Figure 5. Viral dacryoadenitis showing characteristic "S"-shaped edge of upper lid. Source: James H. Brien, DO.

Dacryoadenitis describes inflammation of the lacrimal gland, not the lacrimal sac or duct. The gland resides in the superior-lateral aspect of the upper lid area. Therefore, with dacryoadenitis, one would expect to see swelling and/or erythema of the lateral area of the upper lid, which typically results in an "S" shape configuration to the edge of the upper lid (Figure 5).

Columnist comments:

Over the years, I have shown other case s of dacryoadenitis (in December 1989, August 2005 and

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Orbital Cellulitis And Its Link To Dental Health

Orbital and preseptal cellulitis are more frequently seen in children.

Incisive Bite

BELIEVE it or not, infections that start in your mouth or sinuses can spread to other parts of your body.

One example of this type of complication is orbital cellulitis, a dangerous infection that, if not treated promptly, can lead to blindness or other serious, long-term consequences.

Here's what you need to know about this condition and how to prevent it.

Orbital vs preseptal cellulitis

Cellulitis is a type of skin infection and there are different subcategories which describe the part of the body that's affected.

Cellulitis classified as "orbital" is an infection that begins deep in the orbital septum, which is the thin membrane between the eyelids and the bony eye socket. Preseptal cellulitis is an infection of the eyelid and surrounding skin. While preseptal is more common, orbital may be more serious — and both are more frequently seen in children.

Causes and dental origin

It's reported that more than 90 per cent of orbital cellulitis cases in young adults and children are due to an underlying bacterial sinus disease, especially involving the ethmoid sinuses. These infections can also be caused by trauma that has damaged the orbital septum area or by infected adjacent areas.

This eye infection can also have a dental origin. Dental infections, including severely decayed teeth or an abscessed tooth, can sometimes spread to the orbital area. Recent dental treatment may also contribute to the development of this condition.

Symptoms and complications

Both orbital and preseptal cellulitis may cause fever and discolouration of the eyelid. Swelling can also occur, which may make opening the eyelid difficult. Serious cases of orbital cellulitis usually involve pain whenever moving, along with decreased ability to move the eye and, sometimes, vision problems.

If the infection originated from the sinuses, the patient may have nasal discharge. If the infection has a dental origin, the patient may have gum pain or gum swelling. However, in the earlier infection stages, these symptoms may be more subtle or absent.

Because orbital cellulitis can result in serious complications, such as meningitis and vision loss, anyone with symptoms of cellulitis should seek medical attention immediately.

Diagnosis and treatment

If your doctor suspects cellulitis in your orbital septum they may refer you to an ophthalmologist, who specialises in diseases of the eye. This infection can progress rapidly, so the common procedure is to admit patients to the hospital for frequent monitoring.

Doctors will typically perform blood tests and, if a child is very sick, possibly a spinal tap. X-rays of the sinus areas are helpful for diagnosis, as are computerised tomography (CT) scans and magnetic resonance imaging of the sinuses and eye area.

Using a sterile cotton swab, a medical professional may also gather a sample of cells and fluids from the eyes, nasal passage and the throat for examination. This can help to pinpoint the source of the primary infection and guide your doctor in prescribing the appropriate antibiotics.

Doctors usually treat hospitalised patients with antibiotics administered through a vein. In some cases, surgery may be needed to drain an abscess or relieve pressure in the eye area.

Importance of oral care

Preventing oral infections, such as gum disease and severe tooth decay, may help lessen your chances of having to deal with orbital cellulitis. Keep up with the following oral hygiene tips to ensure your mouth stays as healthy as possible:

• Brush twice a day with a fluoride toothpaste.

• Floss daily.

• Replace your toothbrush regularly.

• Schedule regular dental cleanings and check-ups.

• Call your dentist if you have tooth pain, bleeding gums or any other symptoms of an oral infection.

The good news is you can recover fully from orbital cellulitis with prompt treatment. Be sure to maintain a good oral care routine, and see your doctor if you have a sinus infection that's not getting better. In addition, if you do experience any of the symptoms of orbital or preseptal cellulitis, visit a medical professional as soon as possible.

Dr Sharon Robinson, DDS has offices at Dental Place Cosmetix Spa, located at shop #5, Winchester Business Centre, 15 Hope Road, Kingston 10. Dr Robinson is an adjunct lecturer at the University of Technology, Jamaica, School of Oral Health Sciences. She may be contacted at 876-630-4710. Like their Facebook page, Dental Place Cosmetix Spa.

Keep up with oral hygiene practices to ensure your mouthstays as healthy as possible.

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