Original Article

Nine years’ review on preseptal and orbital cellulitis and emergence of

community–acquired methicillin-resistant Staphylococus aureus in
a tertiary hospital in India

Datta G Pandian, Ramesh K Babu, A Chaitra, A Anjali, Vasudev A Rao, Renuka Srinivasan

Context: Preseptal cellulitis is the commonest orbital disease which frequently needs to be differentiated Access this article online
from orbital cellulitis. Prompt diagnosis and treatment with appropriate antibiotics can prevent vision Website:
loss and life-threatening complications of orbital cellulitis. Aims: To describe the clinical profile of cases www.ijo.in
with preseptal and orbital cellulitis admitted to a tertiary care hospital during a period of nine years. The DOI:
causative organisms and the clinical outcome were analyzed. Settings and Design: Retrospective descriptive 10.4103/0301-4738.86309
case study done in a tertiary care hospital in South India. Material and Methods: The in-patient records PMID:
***
of patients with preseptal and orbital cellulitis were reviewed from 1998 to 2006. The factors reviewed
included ocular findings aiding in the distinction of the two clinical conditions, the duration of symptoms, Quick Response Code:
the duration of hospital stay, microbiological culture report of pus or wound swab, blood culture, drugs
used for treatment, the response to therapy and complications. Statistical Analysis Used: Descriptive
analysis. Results: One hundred and ten cases, 77 patients with preseptal cellulitis and 33 patients with
orbital cellulitis were reviewed. Five percent of children and 21% of adults presented with cutaneous
anthrax contributing to preseptal cellulitis. Thirty-nine percent cases with orbital cellulitis were caused
by methicillin-resistant Staphylococcus aureus (MRSA). Conclusions: This study has helped in identifying
organisms which cause orbital infections, especially community-acquired MRSA. It indicates the need for
modifying our empirical antimicrobial therapy, especially in orbital cellulitis.

Key words: Anthrax, community-acquired methicillin-resistant Staphyloccus aureus, orbital cellulitis,

preseptal cellulitis.

Orbital cellulitis can be classified as preseptal and post-septal Materials and Methods
cellulitis based on the anatomic landmark, the orbital septum.
The septum forms a barrier, preventing the spread of superficial The in-patient records of patients with preseptal and orbital
infection into the deeper orbit. Orbital infection limited anterior cellulitis were reviewed from 1998 to 2006. The clinical details
to the septum is called preseptal cellulitis and that posterior of the patients were noted and analyzed. Subjects of age 13
to the septum is termed as post-septal or orbital cellulitis. years or below were considered to belong to the pediatric
Clinical distinction between the two is important as the ocular age group. Patients were classified as having preseptal or
morbidity and prognosis differs. orbital cellulitis based on the clinical finding. Presence of lid
edema, restricted ocular movements, proptosis, loss of vision
Preseptal cellulitis is characterized by lid edema, warmth, and relative afferent pupillary defect were looked for. Orbital
erythema and tenderness. The distinctive features of orbital cellulitis was diagnosed in the presence of any three of the
cellulitis are proptosis and limitation of ocular movements.[1] above five clinical findings. Preseptal cellulitis was diagnosed
Additional useful signs are chemosis of bulbar conjunctiva, when a patient had lid edema with warmth and tenderness
reduced visual acuity, afferent pupillary defect and toxic with no additional ocular findings.
systemic symptoms. Prompt diagnosis and treatment of orbital
cellulitis is vital as it is associated with serious complications The factors reviewed in the study included ocular findings
like cavernous venous thrombosis, visual loss, meningitis, brain aiding in the distinction of the two clinical conditions,
abscess and sepsis.[1,2] the duration of symptoms at the time of presentation, the
duration of hospital stay, microbiological culture report of
In this study, we reviewed the in-patient records of patients pus or wound swab, blood culture, drugs used for treatment,
with preseptal and orbital cellulitis over nine years in a tertiary care response to therapy and complications. Other parameters
hospital. The clinical findings, causative organism, management studied were general physical examination, systemic blood
and complications of the two conditions are illustrated. counts and temperature. Wound swab was taken either from
the site of infection or ulceration or conjunctival sac. This was
immediately sent for culture and sensitivity. Pus was examined
Department of Ophthalmology, Jawaharlal Institute of Postgraduate by Gram’s staining, KOH mount and cultured on blood agar,
Medical Education and Research, Pondicherry, India chocolate agar and Sabouraud’s dextrose agar. Radiological
Correspondence to: Dr. Datta Gulnar Pandian, No 14, G N Palayam, investigations like X-ray or computed tomography (CT) orbit
Arumbarthapuram, Pondicherry - 110, India. E-mail: dattagulnar12@ and paranasal sinuses were taken in all cases of or suspected
rediff.com orbital cellulitis. Both clinical improvement and improvement
Manuscript received: 12.02.10; Revision accepted: 02.11.10 in vision were considered in outcome measures.
432 Indian Journal of Ophthalmology Vol. 59 No. 6

Results of hospital stay was 5.25 (±3.81) days. The majority of them,
89% (n=69), were treated in 10 days or less while 10% (n=8)
One hundred and ten patients with preseptal and orbital cases were hospitalized for a longer duration. Visual acuity at
cellulitis were identified. Seventy-seven patients had preseptal presentation was better than 20/60 in 14 patients (74%) in the
cellulitis and 33 patients had orbital cellulitis [Table 1]. It was adult age group.
noted that all cases with suspected orbital cellulitis and cases
of preseptal cellulitis in the pediatric age group were admitted. In those with orbital cellulitis, the average duration of
Adult patients with preseptal cellulitis were admitted if there symptoms was 8.89 (±8.02) days in the adult group and 10.64
was tense swelling of the lids with inability to open the lids, (±9.41) days in the pediatric group. Patients who presented
lid abscess, systemic toxemia or poor response to therapy with late and those with associated sinusitis had increased ocular
oral antibiotics. morbidity. The average hospital stay was 13.69 (±9.76) days.
Nineteen patients had a prolonged hospital stay of more than
Among patients with preseptal cellulitis, 75% (n=58) were 10 days. Visual acuity at presentation was less than 20/60 in 15
children while adults accounted for 24% (n=19) of cases. The adult patients. Two cases however had visual acuity of 20/20.
mean age was 3.62 years and 34.2 years in the pediatric and Three patients could not perceive light at presentation.
adult group, respectively. Sex distribution was equal in adults
with male preponderance in children. In patients with orbital Blood was cultured only in patients with suspected
cellulitis, 57% (n=19) were adults while children accounted for septicemia; 17 patients with preseptal cellulitis and all cases
42% (n=14) of cases. The mean age was 4 years and 45 years in with orbital cellulitis. There was no growth in the former group,
the pediatric and adult group, respectively. Sex distribution was while organisms (Klebsiella pneumonia and Staphylococcus aureus)
equal in children with male preponderance in adults. were isolated in two children with orbital cellulitis.

An important factor predisposing to both clinical entities was Among the culture-positive patients, Staphylococcus aureus
injury, 21% in preseptal cellulitis and 24% in orbital cellulitis. was the most common organism isolated in both groups.
In children, additional predisposing factors noted were insect Wound swab culture was positive in 78% cases (n=26) of orbital
bite (10%), hordeolum and molluscum contagiosum of the lid cellulitis. Methicillin-resistant Staphylococcus aureus (MRSA)
with secondary bacterial infection. Among adults, since most of was cultured from 38% cases (10 cases, four children and six
them were laborers, injury with stick and thorn while at work adults) followed by coagulase-negative staphylococcus (23%)
was the predisposing factor in nine cases and it was sinusitis and Staphylococcus aureus (15%). The other organisms isolated
in five patients. One patient had fungal pansinusitis. were Streptococcus pyogenes, Klebsiella and Aspergillus [Table 2].
Conjunctival and wound swab cultures showed no growth in
The average duration of symptoms for patients with 37% patients of preseptal cellulitis and 21% of orbital celllulitis.
preseptal cellulitis was 4.05 (±2.54) days in the adult group and
5.96 (±11.04) days in the pediatric group. The average duration Three children and four adults presented with cutaneous
anthrax contributing to preseptal cellulitis [Fig. 1]. None of the
patients with orbital cellulitis had such lesions.
Table 1: Summary of results In patients with preseptal cellulitis, radiological
Parameter Preseptal cellulitis Orbital cellulitis
investigations were done only in whom there was a suspicion
of spreading cellulitis, to rule out orbital cellulitis and sinusitis.
Total No. of cases 77 (70%) 33 (30%) No abnormality was detected in patients in whom these
No. of pediatric cases 58 19 investigations were performed.
No. of adult cases 19 14
Predisposing factors Injury Injury
Insect bite Sinusitis Table 2: Organisms isolated
Stye
Molluscum Organism isolated Number Percentage
contagiosum Preseptal cellulitis
Duration of symptoms 5.25 (±7.59) days 9.63 (±8.54) days Staphylococcus aureus 25 52
Duration of hospital 5.25 (±3.81) days 13.69 (±9.76) days Streptococcus pyogenes 8 16
stay
Bacillus anthracis 7 14
Culture positivity 62% 78%
Enterobacter 4 8
Complications 15% 48%
Acinetobacter 2 4
Adults Facial cellulitis - 1 Retrobulbar abscess
Lid abscess - 1 -1 Pseudomonas aeruginosa 2 4
Lid abscess - 3 Orbital cellulitis
Scleral abscess - 2 Methicillin-resistant Staphylococcus 10 38
Choroiditis - 2 aureus
Panophthalmitis - 2 Coagulase-negative Staphylococcus 6 23
Retinal detachment - 1
Staphylococcus aureus 4 15
Children Facial cellulitis - 4 Lid abscess - 2
Lid abscess - 4 Intraconal abscess - 2 Streptococcus pyogenes 4 15
Acute dacryocystitis Panophthalmitis - 1 Aspergillus 1 3
-2 Klebsiella 1 3
November - December 2011 Pandian, et al.: Preseptal and orbital cellulitis in India 433

Investigations such as CT scan, ultrasonography (USG) All patients were treated with parenteral antibiotics.
orbit [Fig. 2] and X-ray orbit were done in patients with Crystalline penicillin and gentamicin were the most frequently
orbital cellulitis. X-ray orbit was done in all patients to rule out used antibiotics in both groups of patients. Other antibiotics
associated sinusitis. CT scan was done in patients with severe were substituted or added for some patients based on the
proptosis and in whom panophthalmitis or cavernous venous culture sensitivity reports and in whom response was poor
thrombosis was suspected. CT scan was done in 20 patients even after four days to one week of therapy [Table 3]. Surgical
with orbital cellulitis and six patients with preseptal cellulitis. treatment in the form of incision and drainage of abscess was
Evidence of haziness of one or more sinuses associated with done in patients with lid or orbital abscess [Fig. 3].
orbital cellulitis was present in plain paranasal sinus (PNS) In preseptal cellulitis patients, associated complications in
roentgenograms and CT scans of 15% patients. While sinusitis the form of facial cellulitis [Fig. 4] and lid abscess and acute
was the most common radiological finding in the adult group, dacryocystitis were seen in 10 children and two adults (15.58%
lid abscess, intraconal abscess and panophthalmitis were cases). In children two cases each of acute dacryocystitis,
the findings seen on radio-imaging in the pediatric group. lid abscess and four cases of facial cellulitis were noted.
Subperiosteal abscess was not reported among our patients Complications were more frequent in the orbital group
who underwent CT imaging. (48%), in adults, in the form of retrobulbar abscess, lid and
scleral abscess, choroiditis, panophthalmitis, papillitis and
retinal detachment. Children with orbital cellulitis had lid
abscess, intraconal abscess and panophthalmitis as associated
Table 3: Drugs used for treatment
complications.
Drugs Children Adults
A majority of patients in the preseptal group showed clinical
Preseptal Cellulitis improvement with treatment. At initial presentation itself,
Crystalline Penicillin 46 12 visual acuity remained unaffected in most of these patients.
Gentamicin 50 13 In the orbital group, improved outcome, either clinical or
Cloxacillin 7 1 visual was seen in 60% (n=20) cases. Adults had slightly better
Metronidazole 4 4 outcome; 63% improved, while in children, improvement was
seen only in 57% cases. The causes for poor outcome in cases
Amoxicillin 4 0
with orbital cellulitis were panophthalmitis (n=2) [Fig. 5],
Ampicillin 3 2
perforated scleral abscess (n=1), phthisis bulbi (n=2), choroiditis
Cephalexin 2 0 (n=2), orbital abscess (n=4) and retinal detachment (n=1). The
Ceftriaxone 1 4 first three patients were treated with evisceration. Six patients
Cifrofloxacin 1 0 lost vision due to these complications of orbital cellulitis.
Orbital Cellulitis
Crystalline Penicillin 9 14 Discussion
Gentamicin 12 16 Amongst the cases of orbital cellulitis, preseptal celullitis
Cloxacillin 6 3 constituted 70% and postseptal cellulitis 30%. Children
Ampicillin 1 1 constituted the majority of cases with preseptal cellulitis while
Ceftazidime 1 1 the more serious orbital cellulitis was more frequently seen in
Cefotaxime 0 1
the adult population. Staphylococci followed by streptococci
were the leading causative organisms in our series which is
Vancomycin 1 0
Cifrofloxacin 0 1

Figure 2: Ultrasound B-scan image of orbital abscess. Well-defined

encapsulated lesion measuring 11.9 x7.9 mm filled with low echogenic
Figure 1: Cutaneous anthrax causing preseptal cellulitis in a child content
434 Indian Journal of Ophthalmology Vol. 59 No. 6

similar to other previous reports.[1,3] Thirty-eight percent cases patient’s immune system to overcome the remaining infection.[8]
with orbital cellulitis were caused by MRSA. But none of these
Hemophilus influenzae has been one of the most common
patients had recent hospitalization implying that the infection
organisms causing orbital cellulitis in the pediatric age group
was community-acquired. Another study has shown that
prior to 1990.[9,10] There has been a decline in the number
community-acquired (CA)-MRSA is emerging as a common
of invasive diseases and periocular infections caused by
cause of preseptal cellulitis.[4] The prevalence of CA-MRSA
this pathogen.[9,10] The reduction in the number of cases of
infection is increasing worldwide over the last two decades.[5,6] orbital cellulitis caused by it cannot be solely attributed to the
Though CA-MRSA is more virulent than hospital-acquired introduction of HiB vaccination as non-typable Hemophilus
MRSA, due to the secretion of cytotoxin Panton-Valentine influenzae is the common cause of sinusitis.[9,10] Introduction
Leucocidin (PVL), it is more susceptible to non-β-lactam of better antibiotics, use of antibiotics prior to hospitalization,
antibiotics like tetracyclines, trimethoprim/ sulfamethoxazole, herd immunity and the cyclical nature of the disease would
fluoroquinolones and clindamycin.[5-7] For potentially severe have led to its downfall.[9,10]
clinical forms, linezolid, tigecycline, daptomycin, teociplamine
and vancomycin are effective. Guidelines suggest the use of non- Bacillus anthracis was isolated from seven cases with
β-lactam antibiotics in places where the prevalence of CA-MRSA preseptal cellulitis [Fig. 4]. The significance is that anthrax of
exceeds 15%, though in many patients with CA-MRSA infection, the eyelid can lead to cicatrisation and ectropion.[11-13] In our
β-lactam antibiotics continue to be prescribed.[1] In a study done in series all patients responded well to intravenous penicillin and
Taiwan, most of the soft-tissue infections caused by CA-MRSA did not develop complications.
resolved irrespective of the antimicrobial sensitivity pattern In older series, CT helped in the diagnosis when clinical
of the organism.[8] A drug which may not be effective against features were not yet marked, aided in localizing the
an organism in vitro can be efficient in vivo by eliminating the pathology to the anatomical spaces in the orbit and ruling
susceptible subpopulation of the bacteria and helping the out any associated sinusitis.[2,14] In our series, CT scan helped
to diagnose intraconal and extraconal orbital abscess in two
patients and to diagnose panophthalmitis in two cases with
orbital cellulitis.
All patients with preseptal cellulitis resolved without any
sequelae. Ocular complications occurred in the orbital group.
Six patients lost vision due to orbital cellulitis.
All cases were empirically treated with intravenous
penicillin and gentamicin to cover both Gram-positive and
-negative organisms. Cephalosporins, vancomycin and other
antibiotics were given based on the sensitivity pattern or if
there was no clinical improvement with empirical therapy.
The sixteen patients with orbital cellulitis and 16 patients with
preseptal cellulitis didn’t respond to empirical antibiotics and
required higher generation antibiotics. This may be due to the
change in the sensitivity pattern of the organisms.
Since almost 50% of our patients with orbital cellulitis
Figure 3: Orbital cellulitis with orbital abscess with multiple discharging required a switch in the empirical antibiotics (penicillin and
sinuses gentamicin) used, we recommend the combination of cloxacillin

Figure 4: Preseptal cellulitis with spreading facial cellulitis Figure 5: Panophthalmitis secondary to orbital cellulitis
November - December 2011 Pandian, et al.: Preseptal and orbital cellulitis in India 435

and third-generation cephalosporin or a fluroquinolone as the 2010;16:647-55.

empiric therapy for the management of orbital cellulitis in our 7. Gelatti LC, Bonamijo RR, Becker AP, d’Azevedo PA. Methicillin
population. Larger studies are required to resolve the role of resistant Staphylococcus aureus: Emerging community dissemination.
ancillary antimicrobial agents in CA-MRSA infections. An Bras Dermatol 2009;84:501-6.
8. Teng CS, Lo WT, Wang SR, Tseng MH, Chu ML, Wang CC. The
Based on this nine-year review, it can be concluded that role of antimicrobial therapy for treatment of uncomplicated skin
preseptal cellulitis remains the commonest among orbital and soft tissue infection from community associated methicillin
infections, of which Staphylococci and Streptococci are the most resistant Staphylococcus aureus in children. J Microbiol Immunol
common causative organisms. Community-acquired MRSA is Infect 2009;42:324-8.
often implicated in orbital cellulitis, which is associated with 9. Ambati BK, Ambati J, Azar N, Stratton L, Schmidt EV. Periorbital
more ocular morbidity and prolonged hospital stay. It indicates and orbital cellulitis before and after the advent of haemophilus
the need for modifying our empirical antimicrobial therapy, influenzae type B vaccination. Ophthalmology 2000;107:1450-3.
especially in orbital cellulitis. 10. Donahue SP, Schwartz G. Preseptal and orbital cellulitis in
childhood: A changing microbiological spectrum. Ophthalmology
References 1998;105:1902-6.
11. Thappa DM, Karthikeyan K, Rao VA. Cutaneous anthrax of the
1. Liu IT, Kao SC, Wang AG, Tsai CC, Liang CK, Hsu WM. Preseptal eyelid. Indian J Dermatol Venereol Leprol 2003;69:55.
and orbital cellulitis: A 10-year review of hospitalised patients. J
Chin Med Assoc 2006;69:415-22. 12. Soysal HG, Kirath H, Recep OF. Anthrax as the cause of preseptal
cellulitis and cicatricial ectropion. Acta Ophthalmol Scand
2. Bergin DJ, Wright JE. Orbital cellulitis. Br J Ophthalmol 1986;70: 2001;79:208-9.
174-8.
13. Amraoui A, Tabbara KF, Zaghloul K. Anthrax of the eyelids. Br J
3. Hodges E, Tabbara KF. Orbital cellulitis: Review of 23 cases from Ophthalmol 1992;76:753-4.
Saudi Arabia. Br J Ophthalmol 1989;73:205-208.
14. Zimmerman RA, Bilaniuk LT. CT of orbital infection and its cerebral
4. Blomquist PH. Methicillin-resistant Staphylococcus aureus infections complications. AJR Am J Roentgenol 1980;134:45-50.
of the eye and orbit. Trans Am Ophthalmol Soc 2006;104:322-45.
5. Carvalho KS, Mamizuka EM, Filho PPG. Methicillin/ oxacillin
resistant Staphylococcus aureus as a hospital and public health threat Cite this article as: Pandian DG, Babu RK, Chaitra A, Anjali A, Rao VA,
in Brazil. Braz J Infect Dis 2010;14:71-6. Srinivasan R. Nine years' review on preseptal and orbital cellulitis and
emergence of community-acquired methicillin-resistant Staphylococus aureus
6. Milstone AM, Canoll KC, Ross T, Shangraw KA, Perl TM. in a tertiary hospital in India. Indian J Ophthalmol 2011;59:431-5.
Community associated methicillin resistant Staphylococcus aureus
strains in paediatric intensive care unit. Emerging Infect Dis Source of Support: Nil. Conflict of Interest: None declared.

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