Diagnosis: Preseptal (periorbital) cellulitis secondary to a retained ocular/adnexal foreign body
This case illustrates a 20-year-old female collegiate volleyball player presenting with acute unilateral upper eyelid swelling and erythema after trauma. It emphasizes the importance of distinguishing preseptal cellulitis from orbital cellulitis at the bedside through careful assessment of visual acuity, pupil response, extraocular motility, proptosis, and chemosis, particularly in athletes with potential retained foreign bodies.
A 20-year-old otherwise healthy female collegiate volleyball player presents 48 hours after being struck on the right upper eyelid by a volleyball during practice. She reports progressive swelling, warmth, erythema, and deep aching pain in the affected area. On examination, there is tense, brawny erythematous edema of the right upper eyelid with mechanical ptosis and mild tenderness. The globe appears white and quiet, with intact visual acuity (20/20 OU), equal and reactive pupils, and full painless extraocular movements. Notably, there is no proptosis, chemosis, or pain with eye movement. A careful slit-lamp examination reveals a small embedded foreign body along the tarsal conjunctiva with surrounding focal injection.Normal visual acuityFull painless extraocular movementsNo proptosisNo relative afferent pupillary defectNo chemosis
The patient was well until 48 hours prior to presentation when she sustained a mechanical eyelid trauma from a volleyball impact. Over the next 24 hours, she developed progressive swelling, erythema, and warmth in the right upper eyelid, accompanied by deep aching pain. She denies fever, vision changes, diplopia, sinus symptoms, or systemic illness. The patient occasionally wears soft contact lenses but had glasses on during practice.No immunosuppressionUp-to-date tetanus vaccinationNo recent dental or sinus infectionsNo history of animal or human bitesNo insect stingsNo prior similar episodes
Acute / First-Line ManagementCareful slit-lamp examination with eyelid eversion to identify and remove any retained foreign body under topical anesthetic, serving both diagnostic and therapeutic purposes.Copious irrigation if indicated.Ophthalmology consultation in cases of uncertainty or high risk.Oral empiric antibiotics for mild-to-moderate preseptal cellulitis in an immunocompetent adult: amoxicillin-clavulanate 875/125 mg PO BID for 7-10 days; alternatives include clindamycin 300-450 mg PO QID or trimethoprim-sulfamethoxazole DS BID + cefpodoxime if MRSA risk is high or if there is a penicillin allergy.Warm compresses and analgesia with acetaminophen or NSAIDs.Tetanus update if not current.Follow-up in 24-48 hours to confirm response.Workup and Diagnostic ConfirmationThe diagnosis is primarily clinical.CT of the orbits with contrast is indicated if any orbital signs appear (vision loss, proptosis, ophthalmoplegia, pain with extraocular movements, RAPD), if the patient is younger than 1 year, if there is no improvement at 24-48 hours, or if a deeper or sinus source is suspected.Culture of any expressible purulent material or removed foreign body.Blood cultures only if the patient is systemically ill or febrile.Long-Term ManagementCriteria for IV antibiotics and inpatient admission include the presence of any orbital signs, systemic toxicity, immunocompromise, age For severe disease or suspected orbital extension, use vancomycin + ceftriaxone ± metronidazole.Sports counseling on protective eyewear (polycarbonate sports goggles) for high-risk sports.Emphasize contact-lens hygiene.Establish a clear return-to-play plan only after complete resolution of erythema and edema.
Orbital (postseptal) cellulitis: Characterized by proptosis, ophthalmoplegia, pain with extraocular movements, vision changes, and relative afferent pupillary defect. Represents a surgical and infectious disease emergency, almost always secondary to sinusitis.Internal/external hordeolum (stye): Presents as a focal tender pustule along the lid margin without diffuse cellulitis.Acute chalazion: Typically a subacute, non-tender nodule that lacks warmth or systemic signs.Preseptal cellulitis from sinusitis: Often presents with URI prodrome, sinus tenderness, and is more common in pediatric populations.Allergic contact or angioedema of the eyelid: Usually bilateral and intensely itchy, with no warmth or true tenderness present.Insect-bite reaction: Characterized by a central punctum, intense itching, and possible linear streaking.Periorbital herpes zoster ophthalmicus: Demonstrates vesicles in the V1 distribution, Hutchinson's sign, and often precedes with prodromal pain.Dacryocystitis or dacryoadenitis: Localized swelling over the lacrimal sac or gland with distinct anatomic distribution.
High-Yield PearlsThe bedside distinction between preseptal and orbital cellulitis hinges on visual acuity, pupils, motility, proptosis, and chemosis.Always evert the lid in cases of post-traumatic eyelid swelling; a retained foreign body is a missable but reversible cause of symptoms.Outpatient management with amoxicillin-clavulanate for 7-10 days is appropriate for mild preseptal cellulitis in an immunocompetent adult, with MRSA-active alternatives when indicated.Imaging (CT orbits with contrast) is reserved for the presence of any orbital sign, patients under 1 year of age, those who are immunocompromised, or if there is no improvement at 24-48 hours.Admit and switch to IV antibiotics if any orbital sign or signs of systemic toxicity are present.Sports-related ocular trauma is a significant preventable cause of injury; counsel athletes on the use of polycarbonate protective eyewear.Do not miss zoster ophthalmicus (V1 vesicles, Hutchinson's sign) as a potential mimicker of preseptal cellulitis.'The swollen lid is preseptal until the globe tells you otherwise.'
Tags: preseptal cellulitis, periorbital cellulitis, foreign body, sports medicine, eyelid, infection