Preseptal or Orbital Cellulitis Clinical Pathway — All Settings

Differential Diagnosis

There are a number of important diagnoses that can mimic orbital or preseptal cellulitis; consider the differential diagnoses listed below. A careful history and physical examination can help make these distinctions, and if the diagnosis is unclear, an ophthalmology service consultation is indicated.

Clinical Presentation	General Periorbital Appearance and Comments	Eye Lid Appearance	Presence of Discharge
Orbital Cellulitis	Eyelid swelling with one or more orbital signs	Swelling Erythema Warm to touch	Uncommon
Preseptal Cellulitis	Eyelid swelling without orbital signs	Swelling Erythema Warm to touch	No
Dacryoadenitis	Inflammation of lacrimal gland located in the upper, outer eyelid Infectious or inflammatory	Inflammation at site of lacrimal gland Erythema may be present	No
Dacryocystitis	Inflammation of the nasolacrimal sac, located just below and medial to the inner corner of the eyelids Requires intravenous antibiotics and surgical probing	Focal swelling, tenderness, erythema inferior and medial to the medial canthal (eyelid corner)	No
Chalazion (aka Stye)	Obstruction of the meibomian glands results in focal, non-infectious inflammation of the eyelid. Can be associated with secondary cellulitis	Focal swelling/nodule at the eyelid margin, with or without pustule	Usually no, but may have discharge if lesion drains
Conjunctivitis	Inflammation of the conjunctiva, caused by infectious (viral or bacterial), allergic or inflammatory process	Red ocular surface and/or inside of everted eyelids may have significant secondary lid edema with mild non-tender erythema or warmth, may have white/yellow inflammatory membrane inside everted eyelids	May have significant discharge, which can be mucoid, mucopurulent, or purulent
Orbital tumor Neuroblastoma Leukemia Rhabdomyosarcoma Lymphangioma	Various presentations, including an inflammatory (orbital cellulitis like) appearance or proptosis. Consider imaging if proptosis present to rule out an orbital malignancy.	Proptosis of the eye with or without eyelid swelling or bruising.	No
Uveitis or Endophthalmitis	Intraocular inflammation diagnosed by slit lamp and fundus examinations.	May have significant secondary lid edema but it is without erythema or warmth of lid. Eye surface is red. May see abnormal red reflex.	No
Blepharitis	Inflammation at the eyelid margins (edge) near the lashes	No surrounding cellulitis	No
Local Allergic Reaction/Insect Bite Without Infection	Eyelid swelling without orbital signs May see punctum	Boggy swelling Not indurated +/- warm, erythematous Nontender	No

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

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