**6. Staging**

A computed tomography (CT) scan can delineate the extent of orbital involvement [28, 31, 32].

The modified Chandler staging system is as follows:


Complications of preseptal cellulitis may be progression to stage II and behind of orbital in‐ fections. Preseptal cellulitis in infants and children under the age 5 may be associated with bacteremia, septicemia, and meningitis, and therefore the treatment should start as soon as possible including consultations with a pediatrician. Late complications of preseptal celluli‐ tis include lid abscess, cicatricialectropion, and lid necrosis. Unless appropriately treated, periorbital and orbital cellulitis can result in optic neuritis, opticatrophy, blindness, caver‐ nous sinus thrombosis,superior orbital fissure syndrome, orbital apex syndrome, meningitis, brain abscess, subdural empyema, and even death [34, 35].

#### **7. Treatment**

Earlier diagnosis, expeditious treatment, and improved antibiotics have led to a reduction in serious ocular and central nervous system complications in patients with preseptal cellulitis. Treatment involves management of predisposing conditions, antibiotic therapy, and close observation[36]. Starting the antibiotic therapy at all ages should provide coverage for pathogens associated with acute sinusitis (*S. pneumoniae*, *H. influenzae*, *M. catarrhalis*, *S. pyo‐ genes*) as well as anaerobes and *S. aureus*[37, 38].

Preseptal cellulitis treatment is based on oral antibiotics (outpatient treatment) and antisep‐ tic treatment locally provided that a close follow-up can be ensured. Hospitalization is rec‐ ommended if there is no improvement within 48 hours (or even 24 hours), and parenterally antibiotics (broad-spectrum intravenous antibiotics) are necessary once appropriate cultures have been obtained, undergoing a CT scan to evaluate for orbital cellulitis and its complica‐ tions. Patients with subtle clinical and/or radiographic findings, suggesting that the orbit is involved, should be treated as a case of orbital cellulitis given the serious complications of this entity.

Also, children younger than one year of age, those who cannot cooperate fully, and patients who are severely ill should generally be admitted to the hospital and managed according to the recommendations.

Teenagers and adults usually respond quickly to appropriate oral antibiotics and there is no need for hospitalization unless orbital involvement cannot be excluded or when the clinical situation is severe.

Initial antibiotic selection is based on the history, clinical findings and laboratory studies, and is almost always empiric and based upon knowledge of the common infecting organ‐ isms. Staphylococcus aureus is the most common pathogen in patients with preseptal cellu‐ litis resulting from trauma. The infection usually responds quickly to penicillinase-resistant penicillin. Third-generation cephalosporins or ampicillin have both a broad spectrum cover‐ age including activity against Haemophilusinfluenza, and should be initiated immediately after obtaining the cultures.

Lid abscesses should be drained surgically with the incision and drainage usually per‐ formed directly over the abscess, avoiding the damage of the levatoraponeurosis.

In order to avoid contamination of the orbital soft tissue, the orbital septum should not be opened.

One of the following regimens is suggested for empiric oral treatment of preseptal cellulitis: [39]


**•** Cefdinir (in children: 7 mg/kg twice daily, maximum daily dose 600 mg; in adults: 300 mg twice daily)

The use of clindamycin alone has shown good efficacy for skin and soft tissue infections caused by staphylococci and streptococci.

One of the combination regimens should be used if the patient has not been immunized against Haemophilusinfluenzae.

Topical antibiotics have no role in the treatment of this infection.

Generally, the treatment is recommend for 7 to 10 days, but if signs of cellulitis persist, treat‐ ment should be continued until the eyelid erythema and swelling have resolved or nearly resolved[40, 41].

Recurrent preseptal cellulitis — preseptal cellulitis rarely recurs. When it does, it is usually due to an underlying cause that has not been diagnosed or due to an anatomic abnormali‐ ty[42, 43].

The presence of subperiosteal or intraorbital abscess is an indication for surgical drainage in addition to antibiotic therapy [44, 45]. Surgical drainage is indicated for complete ophthal‐ moplegia and/or significant visual impairment (acute optic nerve or retinal compromise) or large well-defined abscesses [46,47,48]. Depending on the patient condition,sinus surgery and sinus endoscopy are recommended,and for patientswith orbital cellulitis, intracranial abscess drainage, orbital surgery or ethmoidectomy.
