What is the recommended treatment for eye cellulitis with sub and supraorbital swelling?

Treatment for Eye Cellulitis with Sub and Supraorbital Swelling

For eye cellulitis with sub and supraorbital swelling, immediate treatment with broad-spectrum antibiotics effective against streptococci and consideration of MRSA coverage is essential, with hospitalization recommended due to the risk of vision loss and intracranial complications. 1

Diagnosis and Assessment

• Differentiate between:

  • Preseptal (periorbital) cellulitis: Infection limited to eyelids, anterior to orbital septum
  • Orbital cellulitis: More severe infection posterior to septum with sub/supraorbital swelling 2

• Warning signs requiring urgent management:

  • Proptosis, pain with eye movement, movement restriction/diplopia, vision changes 1
  • Fever, tachycardia, confusion, hypotension 1

• Diagnostic imaging:

  • CT of brain and orbits with and without contrast is critical to evaluate for abscess or intracranial extension 3

Antibiotic Treatment Algorithm

Mild Cases (Outpatient-appropriate)

• First-line oral therapy (if no SIRS, altered mental status, or hemodynamic instability):
  • Amoxicillin-clavulanate OR cephalexin OR clindamycin 1
  • Consider oral ciprofloxacin plus clindamycin as an alternative regimen 4

Moderate to Severe Cases (Requiring Hospitalization)

• Indications for hospitalization:

  • Sub and supraorbital swelling (suggests orbital involvement)
  • Concern for deeper/necrotizing infection
  • Systemic signs of infection (fever, tachycardia)
  • Poor adherence to therapy
  • Immunocompromised patient
  • Failed outpatient treatment 1

• IV antibiotic regimen:

  • For typical cases: IV antibiotics active against streptococci (cefazolin, oxacillin) 1
  • If MRSA suspected (penetrating trauma, evidence of MRSA elsewhere, injection drug use): Vancomycin or another antimicrobial effective against both MRSA and streptococci 1
  • For severe infections: Vancomycin plus either piperacillin-tazobactam or imipenem/meropenem 1

Duration of Treatment

• Initial treatment duration: 5 days
• Extend treatment if infection has not improved within this period 1
• Transition to oral antibiotics once significant improvement is observed

Adjunctive Measures

• Elevation of the affected area to promote drainage of edema 1
• Treatment of predisposing factors such as sinusitis, trauma, or dental infection 3
• Systemic corticosteroids (prednisone 40 mg daily for 7 days) could be considered in non-diabetic patients 1

Surgical Management

• Urgent surgical consultation for:
  • Subperiosteal or orbital abscess
  • Progressive orbital cellulitis despite medical therapy
  • Cavernous sinus thrombosis
  • Intracranial extension 2, 5

Specialist Consultation

• Ophthalmology consultation is essential for all cases of orbital cellulitis 3
• Otorhinolaryngology consultation if sinusitis is the underlying cause 5
• Neurosurgery consultation if there is intracranial extension 3

Monitoring and Follow-up

• Daily assessment of:
  • Visual acuity
  • Pupillary responses
  • Extraocular movements
  • Proptosis
  • Systemic symptoms

Complications to Monitor For

• Vision loss
• Orbital compartment syndrome
• Cavernous sinus thrombosis
• Superior ophthalmic vein thrombosis 6
• Intracranial extension (brain abscess, meningitis) 5

Pitfalls to Avoid

• Delaying treatment while awaiting culture results
• Failing to recognize orbital involvement (vs. preseptal cellulitis)
• Inadequate antibiotic spectrum (not covering common pathogens)
• Missing underlying sinusitis as the source of infection
• Overlooking potential for rapid progression to vision-threatening complications