**4. Clinical signs**

Patients with preseptal cellulitis clinically complain of eye pain, redness, periorbital lid swelling, and fever. This is a typical clinicalpresentation. Eyelid edema, a violaceous erythe‐ ma, and inflammation may be severe. Usually the globe is uninvolved; papillary reaction, visual acuity, and ocular motility are not disturbed; pain on eye movement and chemosis are absent. Chemosis may be present in severe cases of preseptal or orbital cellulitis caused by H.influenzae. Focal sinus region tenderness and purulent nasal discharge may be present due to sinus infections. Black eschar within the nasal mucosa indicates a potential fungal in‐ fection. Patients diagnosed with preseptal cellulitis have intact extraocular movements and do not have proptoses that differentiate from orbital cellulitis.

Typically, children with Haemophilusinfluenzae cellulites have a history of recent upper respiratory infection and present with high fever, irritability and coryza. A marked leukocy‐ tosis may be present but this is evident either in preseptal and orbital cellulites [24, 26, 27].

Preseptal cellulitis: Images show preseptal cellulitis in the second day of inflammation. Marked, isolated, and unilateral periocular inflammation may be noted. The patient present‐ ed painless during the eye movement.

**Figure 2.**

#### **Figure 3.**

Same patient with preseptal cellulitis after the treatment: Images show resolved preseptal cellulitis after a whole course of the recommended therapy.

**Figure 4.**

**Figure 5.**

**Figure 2.**

112 Common Eye Infections

**Figure 3.**

**Figure 4.**

Same patient with preseptal cellulitis after the treatment: Images show resolved preseptal

cellulitis after a whole course of the recommended therapy.

**Figure 6.**

**Figure 7.**

**Figure 8.**

#### **Figure 9.**

**Figure 7.**

114 Common Eye Infections

**Figure 8.**

#### **Figure 10.**

Diagnosis is usually based upon the clinical findings, microbiological and radiological ex‐ amination.

Findings on examination include pain on eye movement, afferent pupillary defect, limited extraocular motions, and resistance on retropulsion.

Blood cultures should be obtained as they correlate with orbital pathogens far better in childhood cases than do cultures from the nasopharynx or conjunctiva. Samples of conjunc‐ tival discharge, eyelid lesions, and lacrimal sac material should be sent for culture. Blood culture results are positive in less than 10% of cases of preseptal cellulitis, whereas skin cul‐ ture results tend to be negative.

White blood cell (WBC) counts tend to be elevated and cannot be used to differentiate pre‐ septal cellulitis from orbital cellulitis. Levels of ESR and CRP can help in the differentiation of preseptal and orbital cellulitis. However, it must be kept in mind that all of those high values of routine laboratory results can be seen in preseptal cellulitis.

Biopsy shows edema and polymorphonuclear leukocytes infiltrating tissue planes.

Lumbar puncture may be considered in affected children but not for routine use in the ab‐ sence of meningitis signs.

Orbital ultrasonography can help in diagnosing orbital inflammation, although it requires experienced observers and specialized equipment.

A computed tomography (CT) scan can delineate the extent of orbital involvement[28].

CT scan findings in preseptal cellulitis include the following:


It is quite difficult to distinguish periorbital (preseptal) and orbital cellulitis based just on clinical findings, especially in children. Many of the clinical signs of orbital cellulitis are dis‐ tinctive, such are proptosis andophthalmoplegia, but the correct diagnosis of orbital celluli‐ tis is best confirmed by CT scan with contrast infusion of the orbit[29, 30, 31, 32].
