Periorbital cellulitis, also known as preseptal cellulitis (and not to be confused with orbital cellulitis, which is behind the septum), is an infection of the eyelid and portions of skin around the eye, anterior to the orbital septum.
Periorbital cellulitis must be differentiated from orbital cellulitis, which is an emergency and requires intravenous (IV) antibiotics. CT scan may be done to delineate the extension of the infection.
Affected individuals may experience the following; swelling, redness, discharge, pain, shut eye, conjunctival injection, fever (mild), slightly blurred vision, teary eyes, and some reduction in vision. – Wikipedia
Preseptal: an infection involving the superficial tissue layers anterior to the orbital septum
Orbital septum: a thin membrane that forms the fibrous portion of the eyelids. – Wikipedia
I. How Infection Occurs
The body has lots of mechanisms and barriers in place to prevent infection. The main organ in charge of preventing infection is the skin. You hear a lot of talk about the immune system, but the immune system is just in place to trounce the invaders that got past the skin.
This is why most people can use the filthiest public restroom toilets and not acquire an infection: because the skin on your butt can protect you from most pathogens.
Since the skin is so boss at doing its job, pathogens can only penetrate the body at points where there is no skin, or the skin is broken, or there is an opening in the skin.
Points where there is no skin: Mucus membranes (eyes, nose holes, mouth, ear holes, buttholes, peeholes, vaginae, maybe something else I’m forgetting)
Points where the skin is broken: An injury (a scratch, wound, broken bone, etc.) or an irritation (eczema, itchy insect bite, etc.)
Openings in the skin: the pores (which are the openings in the skin for the hair follicles, and also sebaceous glands)
If you look at this rather cute and possibly a bit inaccurate diagram right here, you will see that the hair follicle penetrates quite deep into the skin layers – deeper even than the heat receptors, which is one of the slowest types of receptors to respond to stimuli (this is why a person might take a moment to jerk their hand off a hot pan handle, while the same person would instantaneously shriek and jump on a chair if a cockroach brushed against their leg – the touch receptor is much higher up on the skin layers than the heat receptor).
You will also note that the hair follicle creates a relatively large opening in the surface of the skin, just begging for pathogens to penetrate it and have a sex party inside the skin, and multiply like wildfire.
Normally, the immune system (as previously mentioned) can trounce invaders that get past the skin. HOWEVER!! If one or more of the following conditions occur:
- The individual is immunosuppressed (the immune system is weak)
- The skin is irritated
- The invader pathogen is particularly strong
Then the pathogen will have their sex party inside the body.
This is exactly what happened in my eyelid about a day or so ago.
II. Etiology; or in layman’s terms, How The Hell Did This Happen?
Now, it is impossible to say with complete certainty what are the exact factors that led to the bacterial orgy inside my eyelid, but I have some guesses:
- I tried out some cheap mascara and eyeliner – this possibly created irritation in my eyelid skin and weakened its defenses
- I slept and bathed in a dirty place – this may be when the bacteria started sneaking its way into my eyelid, via the hair follicles of my eyelashes
- I did not get enough sleep or eat well – this is when I began to be immunosuppressed
- I spent time in an establishment full of smoke – the irritation grew worse, allowing the bacteria to overcome my already distracted and suppressed immune system
- I was further sleep-deprived and thus immunosuppressed- this is when the infection mounted and began to attack my cells full force.
III. Back to the Main Topic At Hand
As per the definition given at the beginning of this… whatever this is, preseptal cellulitis is an infection of the front of the eyelid. It is called preseptal because it is in front of the orbital septum. Behind this septum is the orbit of the eye.
That means that when a patient has preseptal cellulitis, the only thing between that person and a raging infection of the eye itself (literally) is: their immune system, and a thin membrane.
This raging infection of the eye itself is called orbital cellulitis, and it is definitely no fun to have.
Orbital infection can be extensive and severe. Subperiosteal fluid collections, some quite large, can accumulate; they are called subperiosteal abscesses. Complications include vision loss due to ischemic retinopathy and optic neuropathy caused by increased intraorbital pressure; restricted ocular movements (ophthalmoplegia) caused by soft-tissue inflammation; and intracranial sequelae from central spread of infection, including cavernous sinus thrombosis, meningitis, and cerebral abscess. – Merck Manual
Quick lay translation: Orbital infection is a huge bacterial orgy inside your eye socket, wherein bacteria multiply like crazy, creating large amounts of bacteria sludge that can create enough pressure to make your eye pop outwards and make you blind. In addition, the infection can also spread to your sinuses and your fucking BRAIN.
Obviously, preseptal cellulitis and orbital cellulitis are not the same thing. However, they can occur on a continuum – meaning preseptal cellulitis can lead to orbital cellulitis – which should be obvious since, as I’ve stated, the only thing separating the infection in preseptal cellulitis from the orbital is the thin septum.
Additionally, preseptal cellulitis and orbital cellulitis often look so similar at first, that most medical articles online lump them together in one article and emphasize the importance of distinguishing the two.
The danger of preseptal cellulitis progressing to orbital cellulitis is real and present enough that emergency referral – EMERGENCY FUCKING REFERRAL – for preseptal cellulitis is required for the following conditions:
- All children
- Any patient with any indication of possible orbital cellulitis
- All patients who are systemically unwell
- Occasions where there is doubt over the diagnosis
- A patient not responding to treatment; or
- When drainage of a lid abscess is required
IV. The Terrifying Night When I Realized That Bacteria Were Having a Sex Party In My Eyelid
At around midnight, my eye had inflamed to the point where I could no longer see out of it. I had visited a doctor earlier that day, who had prescribed antibiotics, and I had taken the two tablets required that day.
I am familiar with most types of inflammation and skin irritations, and have various creams and oral medicines on hand to treat the common ones (such as eczema, fungal infections, acne, allergies, etc).
I also have an unusually high pain tolerance, such that various professionals who inflict pain for a living (e.g. dentists, salon waxers) have commented on it. Corporal punishment was frustrating for my parents when I was a child because I refused to cry no matter how hard they hit me. I can walk off blows and wounds that would incapacitate most other women. It’s not that I don’t feel the pain, it’s that I can force myself to bear it without complaint if I think I have to. (Perhaps this imperviousness to moderate physical pain is compensated for by my psyche with a heightened sensitivity to emotional pain – but that’s a topic for another time.)
Given these two things about me, I became utterly terrified when the inflammation only got worse and worse despite all the medicines I had taken, and the pain was excruciating.
At around 2AM, I decided I’d better get help. I decided to go to a hospital.
I chose [redacted hospital] for the following reasons:
- It is a hospital for rich people, and I knew that doctors would be too busy with more serious cases to help me at a hospital for poor people
- It was nearby
- I was admitted to that hospital once, three years ago, so there was a chance that they would still have my records
- My psychiatrist is a consultant at that hospital
At this point I was half blind and streaming discharge from one eye. I wanted to call an ambulance but I figured that I would get to the hospital faster if I used an Uber.
This was my first mistake, as I arrived at the hospital looking somewhat chill – that is, not screaming and lying down on a gurney.
Since I lacked a health card, though I entered through the emergency room, I was put in a corner with other people just chilling.
I had started crying while talking to the woman at registration, and she completely ignored this, along with my pleas to let me see a doctor.
I was only loaded into a wheelchair when I began sobbing from the pain. I could no longer see. Vaguely I heard someone protest, and the man wheeling me said, “Umiiyak na e.”
The resident ER appeared, and during the short talk with me, she let slip that admission and intravenous antibiotics were advisable for my condition.
Then some complete asshole of an ophthalmologist appeared. I told him that I needed to be admitted; I needed antibiotics, and I needed painkillers. He ignored this and began examining my vision. I reiterated that there was nothing wrong with my vision; I had an infection in my eyelid. He gave me some stupid bullshit about there being lots more bacteria in the hospital than at home, and advised me to take some meds and put on a hot compress, all of which I had been doing already for more than a day. At some point during the discussion, which was growing heated, I said: “So you’re saying that you want this infection to get worse before you’ll treat me?”
They put me on a gurney. I looked at my watch. It was around 3:10.
I decided to give them 10 minutes to find me help, after which I would leave and try my luck somewhere else.
10 minutes passed. I began to get up from the gurney.
A nurse or possibly a doctor stopped me. I said, “If you’re not going to help me, I’m going to go somewhere else.”
Perhaps frightened by the possibility of lawsuit, they then began actually trying to ascertain my condition. Most importantly, however, they had to find out if I would be able to pay. Since I had no money on me, and the hospital records had been wiped recently, the only thing I could do was name-drop my doctor, who was a psychiatrist.
At that, they called the resident psychiatrist, who started asking me questions to find out if I was a violent mental patient. (“Do you have thoughts of hurting yourself or others?”) I told her that I was properly on psychiatric meds and stable, I just had an infection.
Finally, fucking finally, they administered a painkiller IV. It was around 4AM. I finally got some sleep, as the pain had been keeping me up all night. They wheeled the gurney to an empty corner surrounded by those slide-out divider things. There was a yellow sign on the wall that said FALL RISK, which matched the yellow bracelet on my wrist also marked FALL RISK.
V. In the Morning: I Bully Lots of People
Because no one loves me, and also because I had lost my phone in my haste to get to the ER, I only had a stuffed dog for company that I had brought with me in my backpack. I cuddled it for the few hours while I slept.
When I woke up, the resident psych told me that my psychiatrist was on the way. A nurse brought me a paper tray of food, with the most disgusting fish fillet I had ever tasted in my entire life. (Hospital food must be completely sterile, and this unfortunately involves heat-bombing the fuck out of the cooked foods.) The banana was edible, though. I ate that, along with some wafers in a tin that I had also brought with me. I don’t think they provided any water.
I asked someone for an eye patch. I put it on my eye. I asked for another one to take home with me. I said I’d pay for it. They didn’t give it to me.
My bill for their stupid “care” and “facilities” came to P8,000. I bullied a man at Billing Counter and a woman at Credit Counter before they let me go. The woman at Credit tried to take all my money. I told her, “I still have to get a cab and eat. Do you want me to starve?” She started talking to someone else on the phone, and I walked away from her to try to find the resident psychiatrist. I got all the way back to the ER before someone caught up with me and brought me back to her. I started raising my voice and cursing at her to handle my payment already and stop fucking around. At that, she called her supervisor, who called my doctor, who talked to them, who finally let me go without apologizing at all.
Outside, a doctor in a car yelled to a guard to find me a cab, but he did not.
No one was at the Grab taxi stand, and the line for cabs was about 20 people long. I could not stay in the heat and dust of the streets, as the infection would flare up again.
I walked out of the hospital grounds and tried to hail a cab, but none stopped.
I stood on the island in the middle of the street in the sun. I considered taking off my clothes. Luckily, just a minute or so before I did that, a cab stopped for me. I got in and we talked about our country and how hard it is to live here, me practising my best Filipino accent and pretending to be poor so that he would not overcharge me. It worked.
I went to school because I thought it might be finals. No one was in the room. I went to my professor’s department to try to find him. All the professors there were busily laughing about how they wouldn’t be able to tolerate Duterte as president, while I sat there with my bandaged eye and bandages on my arms from the shots and the IVs, and two hospital bracelets, because nobody knew where my professor was. When I got tired of waiting, I said, “You don’t have any kind of system to keep track of what your schedules are?” The professor I was speaking to, a middle-aged, bespectacled man, said no. I asked then if I could use one of their computers so that I could message someone and ask for help. He said that they were busy with grade checking. Behind him, a bank of unused computers were on. I replied that the library computers were constantly broken because the IT personnel never updated them and never junked old files. He just mumbled something.
I wanted to slap his glasses off his face. Instead, I just put my hands on the table in front him, on top of the papers strewn there, and leaned forward for a moment. I fixed him with my one eye. He stared back. Then I pushed off the table and left.
I needed to find a cab from school to my dorm. I walked into another dorm to ask for help. Upon seeing my bandages and bracelets, the receptionist asked dully, “Mag-iinquire po ba?” I said fuck no, I needed a cab. (Politely.) She told me the guard outside could help me.
The guard outside helped me.
I got a cab. I paid. I went up to my room.
I’ve borne this ordeal with relatively little complaint considering the circumstances, and with fairly good humor. However, I’ve been cursing at a lot of people and I’ve decided to break up with my girlfriend for not taking care of me.
After two days of very little assistance (both physical and financial – my parents only sent me money this morning, after I spent every last peso I have on medicines and food and transportation). I’ve managed to make the swelling go down such that I can see out of the eye again. I am very proud of this.
I am also completely alone, but at least i know for sure now that I know how to take care of myself, just given enough money, and that pretty much no one in my life really cares for me that much.