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Pre-septal and Post-septal Cellulitis

Checked: 23-08-2020 by Vicky Ryan Next Review: 23-08-2021

Overview

Cellulitis around the eye comes in two forms: pre-septal (or periorbital) and post-septal (or orbital).

Pre-septal cellulitis is when the infection is limited to the skin of the eyelids and there is no infection behind the lids, infecting the orbit. The eye is usually white, there is no restriction to eye movement, the eye is not pushed out, the vision is not affected. The patient may, or may not have a temperature. The cellulitis may arise from a defect on the lid in the form of minor trauma, or a blocked cyst, but often can arise from no discernible cause.

Post-septal cellulitis is when the infection is affecting the contents of the orbit. This means that along with cellulitis of the eyelids there is any combination of the following: red eye, pushed out eye (proptosis), restricted eye movements, reduced vision and pupil abnormalities. The patient is more likely to be unwell and more likely to be septic. This most commonly occurs from coexistent sinus disease. This is an emergency.

Who to refer?

It is expected that all cases are referred to the BEH Emergency Department

Red Flags

The BEH Emergency Department should review all cases urgently.

Before referral

The BEH Emergency Department often reviews patients who have been commenced on oral antibiotics for preseptal cellulitis in the community. Only the very mildest pre-septal cellulitis should be managed in primary care, if both patient and clinician are comfortable with this decision. Often pre-septal cellulitis is incorrectly given PO Flucloxacillin in primary care, current microbiology advice is PO Coamoxiclav 625mg TDS for 7 days (if penicillin allergy then Cefalexin 500mg tds or if a type 1 allergy Levofloxacin od all for 5 days).

Out of hours please discuss with the on-call ophthalmologist for advice and guidance.

Orbital Cellulitis is an emergency and requires immediate review and should not be treated in the community.

Referral

Refer to BEH Emergency Department

Resources

These guidelines have been written by Rhys Harrison, consultant ophthalmologist at Bristol Eye Hospital, with thanks to the patients who have kindly given consent to use their photos.

For full ophthalmology guidelines see: Primary Care Ophthalmology Guidance Document

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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