Treatment Plan

Treating a Red, Swollen Eyelid

BY WILLIAM L. MILLER, OD, PHD, FAAO

Eyelid conditions most commonly encountered in our practice involve the lid margin and associated glands that produce the lipid component of the tear film. A less commonly observed eyelid disease is preseptal cellulitis. This infection encompasses the lid and is isolated to the space anterior to the orbital septum. It often presents as an ipsilateral inflamed, swollen, hyperemic eyelid.

Etiology and Diagnosis

You must distinguish preseptal cellulitis from its more severe counterpart orbital cellulitis, which requires emergency intervention with additional imaging and resultant therapeutic IV medications. Common differences that point to preseptal cellulitis rather than orbital cellulitis relate to vision, pain, and appearance. Preseptal cellulitis patients will have normal vision and normal pupil responses. They will also have an absence of pain upon globe movement, but the lid and surrounding adnexa may be painful and tender to the touch. Some preseptal cellulitis patients may also have a mild headache, although it will not be nearly as severe as those experiencing orbital cellulitis. The globe will be positioned normally with little to no conjunctival hyperemia and/or chemosis.

Look for evidence of puncture wounds or trauma in the surrounding cutaneous tissue as well as self-inflicted wounds in patients attempting to ameliorate a hordeolum or chalazion. Assessing any of these is more difficult in an infant or very young child, so maintain a high index of suspicion for orbital cellulitis and take prudent measures when the diagnosis is equivocal.

The mean pediatric age for preseptal cellulitis is 21 months (Givner, 2002) while that for orbital cellulitis is 12 years of age. The former were most commonly caused by trauma or bacteremia while the latter was secondary to sinusitis. Dacryocystitis can also appear as a localized preseptal cellulitis in some of our patients.

There are several causes for preseptal cellulitis including eyelid trauma, cutaneous eyelid infection, and sinusitis. Sinusitis more frequently occurs in children. In the past, cases of preseptal cellulitis resulting from childhood sinusitis were often caused by Haemophilus influenza. However, because of the H. influenzae B (Hib) vaccine, the most common cause is now gram positive cocci. It would be prudent, though, in cases of pediatric preseptal cellulitis to determine whether the child has received the Hib vaccination; this is especially important in cases that do not respond to medical therapy or in cases that are known to be secondary to sinusitis or upper respiratory or otitis media infection.

Trauma has been cited as the most frequent cause of preseptal cellulitis, specifically insect bite trauma in patients ages 6 to 16 (Babar et al, 2009). In cases of an eyelid cutaneous abscess, drainage may be required with resultant laboratory tests to confirm the causative agent. This will necessitate topical antibiotic treatment in addition to oral antibiotics.

Treatment

Treat preseptal cellulitis with oral antibiotics targeting gram positive bacteria. First line treatment can start with Augmentin (Glaxo-SmithKline) tablets 250mg to 500mg three times a day or 875mg tablets twice a day. Prescribe a 250mg chewable tablet twice daily for children weighing less than 40kg. Also consider dicloxacillin 250mg four times a day or 500mg three times a day. In suspected MRSA infections, consider a first-generation cephalosporin or a macrolide. In patients who are allergic to penicillin, substitute the generic sulfamethodxazole/trimethoprim as well as azithromycin (Z-pak) or the fluoroquinolone antibiotic levofloxacin (500mg every day), but use the latter with caution in at-risk patients. CLS

For references, please visit www.clspectrum.com/references.asp and click on document #177.

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Dr. Miller is an associate professor and chair of the Clinical Sciences Department at the University of Houston College of Optometry. He is a member of the American Optometric Association and serves on its Journal Review Board. You can reach him at wmiller@uh.edu.