What is the treatment for eye cellulitis?

Treatment for Eye Cellulitis

For eye cellulitis (orbital or periorbital), treatment should include antibiotics active against streptococci and staphylococci, with initial therapy typically consisting of oral antibiotics for mild cases and intravenous antibiotics for severe cases or those with systemic symptoms. 1

Classification and Diagnosis

Before initiating treatment, it's important to distinguish between the two main types of eye cellulitis:

1. Periorbital (preseptal) cellulitis: Infection anterior to the orbital septum
2. Orbital cellulitis: Infection posterior to the orbital septum (more serious)

Key diagnostic features to assess:

• Eyelid edema, erythema, and tenderness
• Visual acuity changes (suggests orbital involvement)
• Eye movement limitations or pain (suggests orbital involvement)
• Proptosis (suggests orbital involvement)
• Presence of fever or systemic symptoms

Treatment Algorithm

1. Mild to Moderate Periorbital Cellulitis (Outpatient Management)

• First-line therapy: Oral antibiotics active against streptococci and MSSA
  • Adults: Cephalexin 500 mg four times daily for 5-7 days 1
  • Alternative options: Dicloxacillin, clindamycin, or amoxicillin-clavulanate

2. Severe Periorbital Cellulitis or Orbital Cellulitis (Inpatient Management)

• First-line therapy: Intravenous antibiotics
  • Adults: Vancomycin plus either piperacillin-tazobactam or imipenem/meropenem 1
  • Alternative: Nafcillin 1-2 g every 4-6 hours IV or cefazolin 1

3. Special Considerations

• MRSA risk factors (prior MRSA infection, injection drug use, prison history):
  • Add vancomycin, linezolid, or daptomycin to regimen 1
• Post-trauma or post-surgical cases:
  • Consider broader coverage including gram-negative organisms

Duration of Therapy

• Standard duration: 5 days for uncomplicated cases 1
• Extend treatment if infection has not improved within 5 days 1
• Transition from IV to oral antibiotics when clinical improvement is observed

Adjunctive Measures

• Elevation of the affected area to reduce edema 1
• Treat predisposing factors (e.g., sinusitis, dental infections) 1
• Consider systemic corticosteroids in non-diabetic adults to reduce inflammation (prednisone 40 mg daily for 7 days) 1
• For orbital cellulitis, ophthalmology consultation is essential

Prevention of Recurrence

For patients with recurrent episodes:

• Identify and treat predisposing conditions (edema, venous insufficiency) 1
• Examine interdigital toe spaces for fissuring or maceration 1
• For frequent recurrences (3-4 episodes per year), consider prophylactic antibiotics:
  • Oral penicillin or erythromycin twice daily for 4-52 weeks 1

Important Caveats

• Blood cultures are not routinely recommended for typical cases but should be obtained in patients with malignancy, neutropenia, severe immunodeficiency, or systemic symptoms 1
• Hospitalization is recommended if there are concerns for deeper infection, poor adherence to therapy, immunocompromised status, or if outpatient treatment is failing 1
• For orbital cellulitis specifically, some evidence suggests oral ciprofloxacin and clindamycin may be as effective as IV therapy in select cases 2, but this approach should be used cautiously and with close follow-up

The treatment approach should be adjusted based on clinical response within 48 hours. If no improvement is seen, consider broadening antibiotic coverage or reevaluating the diagnosis.