4 possibilities / Differentials In preseptal cellulitis (aka periorbital cellulitis), in contrast to orbital cellulitis proptosis and chemosis are absent; visual acuity, pupillary reactions and ocular motility are unimpaired. (Preseptal cellulitis is an infection of the subcutaneous tissues anterior to the orbital septum.) Modes of intection 1. Exogenous infection may result following skin laceration or insect bites. 2. Extension from local infections such as from anacute hordeolum or acute dacryocystitis. 3. Endogenous infection may occur by haematogenous spread from remote infection of the middle ear or upper respiratory tract. Orbital cellulitis refers to an acute infection of the soft tissues of the orbit behind the orbital septum. Orbital cellulitis may or may not progress to a subperiosteal abscess or orbital abscess In orbital cellulitis, signs of marked orbital inflammation usually precede visual loss. In orbital apex syndrome (“posterior orbital cellulitis”), the opposite occurs. Patients present with severe unilateral visual loss and ophthalmoplegia, but with minimal orbital inflammation. Staphylococcus aureus is the most common infectious microbe, found in 70% of the cases. Streptococcus is the second leading cause. Subperiosteal abscessis collection of purulent material between the orbital bony wall and periosteum, most frequently located along the medial orbital wall. Clinically, subperiostealabscess is suspected when clinical features of orbital cellulitis are associated with eccentric proptosis(as opposed to axial proptosis in case of orbital cellulitis); but the diagnosis is confirmed by CT scan Orbital abscessis collection of pus within the orbital soft tissue. Clinically it is suspected by signs of severe proptosis, marked chemosis, complete ophthalmoplegia, and pus points below the conjunctiva, but is confirmed by CT scan. Or any combination of the above esp. preseptal cellulits + orbital cellulitis I think this is primarily a case of preseptal cellulitis aka periorbital cellulitis + / - orbital cellulitis. The case of preseptal cellulitis is strong, becos the eyelids are clearly inflamed and not merely congested. Additionally if there was orbital cellulitis, then the proptosis due to intraorbital soft tissue swelling would not have allowed the eyelids to be so tightly shut.
this patient could have an underlying ethmoiditis (independent of preseptal cellulits ) and if not contained, would more likely spread to the orbital space leading to orbital cellulitis and abscess ( in preference to the preseptal space ). But ethmoidal cellulitis in isolation won't give u this picture i.e inflammation of the preseptal space ( indicated by marked inflammation and not just congestion of the eyelids ). In orbital cellulitis, there will be concentric proptosis and in ethmoidal abscess, u will have eccentric proptosis ( even if not marked ). In this challenge the brawny eyelids r tightly shut. Dear friend & colleague, pls don't consider this as a rebuttal...it's just a discussion and u have it in u to add a lot of value to this forum. Only by discussing ideas can b xchanged and concepts clarified and those involved will b much smarter and more importantly 'safer' doctors (-:
