A 4-year-old girl is brought to the clinic by her parents for pain and swelling in her right eye for the past 4 hours. The patient and her family recently had cold-like symptoms with rhinorrhea and cough that were improving. The mother reports that the patient appears more tired but has maintained oral intake with good urine output. Otherwise, the patient is healthy without prior medical history. She is up to date on her vaccinations and takes no medications. Temperature is 37.6° C (99.7°F), blood pressure is 100/70 mmHg, and pulse is 104 beats/minute. On physical examination, her pupils are equal, round, and reactive to light. Extraocular movements in her affected eye are limited by swelling but are nonpainful. Her right eyelid is warm and tender to touch with blanching erythema.
There is no proptosis. Which of the following is the most likely region infected?
A) Anterior to the orbital septum
B) Inside the lacrimal duct
C) Inside the orbital space
D) Within the lacrimal glands
E) Within the Meibomian glands
A) Anterior to the orbital septum
This patient with swelling around the eye without emergent signs of visual compromise or proptosis likely has periorbital (preseptal) cellulitis. It is an infection of the skin and eyelid that most commonly occurs in children younger than 10 years of age. This bacterial infection can occur after trauma or ear or sinus infection. The orbital septum restricts the infection from entering the orbit. Common organisms include Staphylococcus aureus, Streptococcus pyogenes, Streptococcus pneumoniae, and Haemophilus influenzae. Adults and children older than one year of age can be treated as outpatients with oral antibiotics. Bacterial infection of the lacrimal duct occurs in dacryocystitis (Choice B). Infection of the orbital space posterior to orbital septum occurs in orbital cellulitis (Choice C). Patients have alarming symptoms of decreased visual acuity, ophthalmoplegia, chemosis, and proptosis. Inflammation of the lacrimal glands occurs in Sjogren syndrome (Choice D). Patients typically complain of blurry vision with dry, itchy eyes. Bacterial infection of the Meibomian glands causes hordeolum (Choice E), which presents as an inflamed tender papule. A hordeolum can develop into preseptal cellulitis.
Key Learning Point
Periorbital (preseptal) cellulitis presents with periorbital erythema and edema, and the infection is anterior to the orbital septum. There are no alarming features such as decreased visual acuity, restricted extraocular movements or proptosis which would suggest orbital infection.
