Findings from a recent study published in Ophthalmic Epidemiology evaluated the incidence rates, risk factors, and economic burden of orbital and preseptal cellulitis in the United States.
Give me some background.
Distinguishing between preseptal and orbital cellulitis is critical for clinicians as orbital cellulitis—while less common—may be associated with significant visual and life-threatening sequelae.
Key characteristics of the two conditions are as follows:
- Preseptal cellulitis
- What it is: An acute infection affecting the eyelid and periorbital soft tissues anterior to the orbital septum
- Sudden onset of erythema, edema, and soreness around the eye while visual acuity and extraocular movements are preserved
- Common in children aged 5 or younger and is typically caused by trauma, insect bites, or contiguous dissemination from nearby structures (ex., sinusitis)
- What it is: An acute infection affecting the eyelid and periorbital soft tissues anterior to the orbital septum
- Orbital cellulitis
- What it is: A serious infection that involves the muscle and fat located within the orbit—though it does not involve the globe itself
- Can occur at any age, but is more common in the pediatric population
- Often preceded by sinusitis as the bacterial infection invades into the postseptal tissues of the eye
- Patients tend to present with similar findings to preseptal cellulitis with additional ocular symptoms, such as proptosis, ophthalmoplegia, i.e., pain with eye movement, decreased vision, and restricted extraocular motility
- Without treatment: Can lead to complications, including vision loss, subperiosteal abscess, orbital abscess, and intracranial extension of the infection
- What it is: A serious infection that involves the muscle and fat located within the orbit—though it does not involve the globe itself
Now, talk about the study.
In this retrospective longitudinal study, investigators utilized data from the U.S. Nationwide Emergency Department Sample dataset.
- Note: The NEDS is the largest all-payer emergency department (ED) database in the U.S. and features national estimates of hospital-owned ED visits.
In total: An estimated 732,105 ED visits with a primary or secondary diagnosis of orbital and preseptal cellulitis from 2006-2018 were included.
Using this dataset, the research team calculated:
- Incidence rates
- Descriptive statistics
- Risk factors
Findings?
The incidence rates of preseptal cellulitis increased from 6.2 in 2006 to 19.2 per 100,000 U.S. population in 2018—indicating a three-fold increase.
- Conversely: Orbital cellulitis incidence rates have decreased from 6.1 to 2.8 per 100,000 U.S. population during this same time period—highlighting just over a two-fold decrease.
Interestingly: Young adults (aged 21-44) made up a majority of patients (31.7%, 90% confidence interval [CI] 30.5-33.0%) with either preseptal or orbital cellulitis.
- However: When stratified by type of infection, children (aged ≤10 years) comprised a majority of patients with orbital cellulitis.
What diagnoses were associated with orbital and preseptal cellulitis?
The most commonly associated diagnoses for both conditions were as follows:
- Hypertension
- Orbital cellulitis: 11.8%
- Preseptal cellulitis: 12.9%
- Tobacco use
- Orbital cellulitis: 11.2%
- Preseptal cellulitis: 9.6%
- Sinusitis
- Orbital cellulitis: 9.2%
- Preseptal cellulitis: 4.3%
Anything else of interest?
When grouped by age, the most common secondary diagnoses slightly changed:
- Children (aged ≤10)
- Orbital cellulitis: Sinusitis, conjunctivitis, and asthma
- Preseptal cellulitis: Sinusitis, diabetes, and hyperlipidemia
- Young adults (aged 21-44)
- Preseptal and orbital cellulitis: Hypertension and tobacco use
- Elderly (aged ≥65)
- Orbital cellulitis: Hypertension, diabetes, and asthma
- Preseptal cellulitis: Tobacco use, conjunctivitis, and asthma
Anything else?
Only 27.6% of patients with orbital cellulitis were admitted and 64.7% of patients were routinely discharged.
- The study authors noted that this may have resulted from coding inaccuracies or be an opportunity to improve the treatment for patients with orbital cellulitis.
The inflation-adjusted ED charges for patients with orbital and preseptal cellulitis from 2006-2018 totaled over $997 million.
In addition: 51.8% of patients presenting to a metropolitan teaching hospital were admitted with an increased odds of admission (odds ratio [OR] 1.62) compared to non-teaching hospitals.
Expert opinion?
“Developing strategies to decrease ED use for milder cases of preseptal cellulitis, while identifying individuals most at risk for complication and subsequent inpatient hospitalization, could help contain costs in the future,” the study authors noted.
Take home.
These findings suggest that orbital and preseptal cellulitis are costly infections in the U.S. with increasing incidence rates for preseptal cellulitis.
High rates of routine discharge from the ED for orbital cellulitis may represent a knowledge gap amongst providers and an opportunity to improve care.
Identifying individuals at risk for infection is key for diagnosis and appropriate triage of care.