Pre-septal and Orbital Cellulitis: A Retrospective Analysis of Manifestations and Outcomes of a Tertiary Center in Kuwait

Introduction Orbital cellulitis is an infectious condition that presents a gap in the literature in regard to its manifestations in the Middle East. A retrospective investigation was undertaken at one tertiary care facility in Kuwait, aiming to augment regional insights into the etiological factors and subsequent outcomes associated with this condition. Methods A retrospective review collected data from 92 patients in a tertiary care center in Kuwait for patients admitted with pre-septal and orbital cellulitis between January 2013 and June 2023. Primary outcomes assessed the resolution of symptoms, categorized as "completely resolved" and "resolved with complications". Secondary outcome measures included patients’ ages, microbiology, laboratory, and radiological findings. Gender, predisposing conditions, surgical status, and orbital involvement were additionally extracted and analyzed descriptively. Results Data of n=92 (56 males and 36 females) were extracted. Ages ranged from 20 days to 18 years, the mean being seven years. Additionally, 52.2% (n=48) were diagnosed with orbital cellulitis, and 42.4% (n=39) were diagnosed with pre-septal cellulitis on admission. Cultures were available for n=60. Specifically, 52.1% (n=48) received CT scans; 6.5% (n=6) MRI scans; and 98.9% (n=91) received antibiotics (microbiology investigated: n=83). Ceftriaxone was used in 82.6% (n=76); 20.6% (n=19) received surgical interventions, and incision and drainage (I&D) were done on 15.2% (n=14). Visual acuity was assessed in 59.7% (n=55) patients. Five (5.43%) reported visual deterioration, and 87 (94.6%) of the outcomes were classified as “completely resolved”. Conclusion Upper respiratory tract infections were the most common documented predisposing risk factor in the development of pre-septal and orbital cellulitis. Adverse outcomes in vision were documented in 5.43% of patients. A paucity of regional data highlights the importance of conducting further studies locally.


Introduction
Orbital cellulitis is characterized by infection of the orbit affecting tissues located posterior to the orbital septum beyond the orbital septum and extending into the orbital cavity.It carries both sight-threatening and potentially life-threatening morbidity [1,2].It can manifest in all age cohorts; however, it predominantly presents in the pediatric population, and its successful treatment requires prompt recognition [3].
The most common organisms causing orbital cellulitis include Staphylococcus aureus and Streptococcus.Infection is most commonly associated with underlying sinusitis but is also caused by dental infection; preseptal cellulitis progression, age, trauma, and foreign bodies [2].
Chandler's classification categorizes orbital cellulitis based on severity and anatomical involvement.It is divided into five stages, each representing a varying level of severity.Chandler group 1 is classed as preseptal cellulitis, while 2-5 are considered post-septal cellulitis, with group 1 being described as edema limited to the eyelid, 2 being inflammation including contents posterior to the septum, 3 being purulent collection between the bony orbit and periorbita, 4 being purulent collection within the orbit itself, and 5 being retrograde phlebitis [4].
Although the mainstay of treatment of orbital cellulitis is intravenous antibiotics, surgical drainage of abscesses may be necessary to relieve pressure and prevent further complications or lack of response to medical treatment [5,6].
There are few studies describing the clinical profile and outcome of orbital cellulitis in countries in the Arabian Gulf.Prior to this study, there exists a study of the microbiology profile of orbital cellulitis population in Saudi Arabia [7] in 2022, a chart review from 1991 to 2005 from a tertiary center in Riyadh [8], and a Saudi Arabian chart review published in 1989 [9].
We sought to describe the clinical manifestations and outcomes of periorbital cellulitis in one tertiary care center in Kuwait and to compare the findings with the clinical features and outcomes of pre-septal and orbital cellulitis outcomes reported in the literature.

Materials And Methods
A retrospective chart review of patients who were diagnosed with positive findings pertaining to the Chandler classification of orbital infections was conducted in Al-Bahar Hospital after obtaining ethical approval from the Kuwaiti institutional review board.The department was able to collect data from individuals admitted to the tertiary care center in Kuwait between the calendar years of 2013-2023, and the department was then able to extract and analyze patient characteristics, investigations, management, and outcomes of patients within these years.

Inclusion Criteria
We have included any patient who was admitted under a preliminary diagnosis of pre-septal cellulitis and orbital cellulitis (Chandler stages [1][2][3][4][5] between January 2013 and June 2023 in an Al-Bahar ophthalmology tertiary care center in Kuwait.

Exclusion Criteria
We excluded patients with insufficient medical records who were not admitted to this health center within the aforementioned timeframes.

Primary Outcome Measures
Our primary outcome measure evaluated the resolution of the conditions, which we defined resolution as the cessation of clinical signs and symptoms at discharge.We categorized outcomes as "completely resolved" and "resolved with complications".Patients with reduced visual acuity and documented adverse outcomes were identified and labeled as "resolved with complications".

Secondary Outcome Measures
Secondary outcome measures include evaluating patients' ages, causative microorganisms, and radiological investigations (CT orbit/MRI scans).
Gender, hospitalization status, ocular findings, etiologic causes, risk factors, immune status, and orbital involvement were also collected.Relevant data were extracted and descriptively summarized to highlight trends in the region.
Admitted patients all underwent adequate ophthalmologic assessments for the sequelae of the disease.

Intervention
Any conservative, medical, or surgical intervention that patients underwent to manage pre-septal or orbital cellulitis.

Statistical Analysis
Descriptive statistics were employed to delineate demographic profiles, discern risk factors, and ascertain prevalence rates for various symptomatic, diagnostic, and management variables.In assessing the risk of bias for this retrospective chart review, several potential sources of bias were considered.Selection bias was mitigated by including all eligible patient records from the specified time frame, ensuring a representative sample.To address information bias, data extraction was performed using a standardized protocol, with multiple reviewers cross-checking the data to enhance accuracy and consistency.Confounding variables, such as patient demographics and co-morbidities, were identified and extracted appropriately.To prevent reporting bias, all relevant outcomes and findings were transparently reported.

Funding and Conflicts of Interest
This research was conducted independently, without any financial support from external funding agencies, commercial entities, or non-profit organizations.Furthermore, the authors declare that they have no competing interests or conflicts of interest that could have influenced the outcomes or interpretations presented in this study.

Results
We have included 92 patients admitted to Al-Bahar Hospital, with 48 being diagnosed with orbital cellulitis, 39 with pre-septal cellulitis, three with subperiosteal abscesses, two with orbital abscesses, and zero with cavernous sinus thrombosis on admission.The gender characteristics of the patients are represented in Table 1.The ages ranged from 20 days old to 18 years old.The mean age that was extracted was seven years old.The gender demographics of the set entailed 56 males and 36 females.

Discussion
Orbital cellulitis is an ocular emergency that requires urgent hospital admission due to complications that include vision loss, blindness, and even death [10].This warrants urgent medical and surgical interventions [2] through the consultation of ophthalmologists and otolaryngologists.Both pre-septal and orbital cellulitis are major infections of the ocular adnexa and orbital tissues [11], with pre-septal cellulitis being defined as an infection anterior to the orbital septum and orbital cellulitis involving the tissues posterior to the orbital septum [12].Diagnosis and management at times may prove to be a challenge for clinicians as manifestations such as induration, erythema, and edema are visually similar [13], with periorbital edema also limiting clinical examination and findings and hindering differentiability between the two conditions [4].Differentiating cases that are clinically difficult to identify would warrant a CT paranasal sinus with contrast within 24 hours of presentation [14].
Whilst sex predilection is not expected to be observed in pre-septal and orbital cellulitis [15], 61% of cases observed in this study were male.November, December, January, and March were months with an increased number of observed presentations, secondary to increased URTI and sinus infections due to the weather [16].The mean age in various studies ranges between four to eight years, which is what we observed in this study [17,18].The frequency of pre-septal and orbital cellulitis in this study proved to be 68/32, differing from similar studies identifying a ratio of 87/13 in pediatric patients [17], a variance likely explained by regional referral practices.
Infective causes (upper respiratory tract infections, fevers (unspecified), and sinusitis) were the leading causes in a majority of cases in this study.Computerized tomography imaging is cited as the most utilized imaging modality in diagnosing sinusitis and evaluating orbital and subperiosteal abscesses [20,21].Imaging was conducted on patients unresponsive to medical therapy or patients who are unable to be examined physically.The reported accuracy of CT imaging diagnosing abscesses ranges between 91% and 100% [20,22].This study identified a total of 31 orbital and subperiosteal abscesses by utilizing CT scans, with the most common presenting complaint being either generalized swelling and patients not being able to open their eyes, serving as a reminder that initial presentations may not reveal occult abscesses revealed through radiological imaging.
Magnetic resonance imaging is the preferred imaging modality in identifying and excluding cavernous sinus thrombosis [23] and is more sensitive in evaluating intra-orbital complications of sinusitis [24].This was utilized in six cases during the study, one of which identified optic neuritis, one with a sixth nerve palsy, and three with intra-orbital abscesses.
In this review, 91 patients underwent an empiric antibiotic regimen, with ceftriaxone being the most commonly prescribed monotherapy in 38 patients.Regimens were decided through symptomatic presentation and were prescribed prior to microbiology results.Similar studies discuss the validity of utilizing cephalosporins, aminoglycosides, and other combinations as appropriate antimicrobial regimens [2].
Surgical interventions were reserved for patients who had compromised visual function or were unresponsive to initial medical management, constituting 21% of patients in this study.This is a significantly higher figure than the 12.4% cited from a United States national study conducted in 2006 [25].This may be attributed to differences in referral structures within local primary and secondary care centers.
No reported patients had symptomatic recurrence and no intraoperative complications were reported in this study.
The strengths of this study include providing the first insights into documented characteristics of orbital cellulitis in Kuwait, providing both a perspective of characteristics and manifestations of the disease in the country and in the region.Other strengths include the high sample size of patients that were documented and the positive patient outcomes identified.Early retrospective studies in a region are significant as they provide a baseline on available data, management practices, and outcomes for future researchers to expand upon, providing valuable insights to those in the region.
The limitations of this study include the study's exclusively descriptive nature alongside its poor follow-up data due to the referral structures present in Kuwait.The study design could have also been optimized had it standardized microbiological investigations for every patient with a suspected positive admission diagnosis.Improvements to the data would also have been optimized with access to multiple primary and secondary center documentation systems, which is difficult to access secondary to the limited available data in certain primary and secondary care centers.This is a limitation for future researchers to address.

Conclusions
Upper respiratory tract infections were the most common documented predisposing risk factor in the development of pre-septal and orbital cellulitis, followed by symptoms of fever and sinusitis.CT and MRI scans proved to be useful imaging modalities in investigating the condition.Approximately two-thirds of patients could be managed with IV antibiotic interventions with ceftriaxone being the most prescribed antibiotic overall.

A 1 -
day history of lid CT orbit: Left orbital cellulitis with post-Left functional 2024 Hayat et al.Cureus 16(7): e65104.DOI 10.7759/cureus.dayhistory of right upper and lower lid swelling post-trauma 2 days prior.Right lid edema and tenderness and erythema.Quiet eye,

TABLE 1 : Genders of patients included in the study
The predisposing variables to the disease are presented in Table2.The most common predisposing condition was upper respiratory tract infection (URTI), present in 44.5% (n=41) patients.The second post-predisposing condition was having a fever of over 38c, present in 21.7% of patients (n=20).

TABLE 2 : Predisposing conditions of patients on presentation
acid in four cases, and clindamycin alone was used for three patients.

Table 5 .
Clinical manifestations of individuals with acute visual deterioration are available in

Table 6 .
Clinical manifestations of individuals with visual improvement during admission are available in Table7.

TABLE 7 : Clinical manifestations of individuals with visual improvements during admission
Admission dates sorted by month are available in Table8.Eighty-seven (94.6%) of patients reported favorable outcomes and were classified as "completely resolved", and n=5 (5.4%) reported visual loss upon discharge and were classified as "resolved with complications".

TABLE 8 : Admission frequency by month
[3]] yields significantly different findings from the available literature, which demonstrated a 41/55 (75%) culture rate depicted in a study conducted by Liu et al.[19].Of the microbiological microorganisms reported in this study, the most common were staphylococcus and streptococcus species, similar to what is reported in the literature[3].