What is the initial management for preseptal periorbital cellulitis?

Initial Management of Preseptal Periorbital Cellulitis

Mild cases of preseptal cellulitis (eyelid <50% closed) should be treated on an outpatient basis with high-dose amoxicillin-clavulanate and daily follow-up until definite improvement is noted. 1

Diagnostic Considerations

Preseptal cellulitis is an infection confined to the eyelids and soft tissues anterior to the orbital septum, which must be distinguished from the more serious postseptal (orbital) cellulitis that involves structures of the orbit.

Key clinical features to assess:

• Extent of eyelid swelling (< or >50% closed)
• Presence of fever
• Visual acuity
• Extraocular mobility
• Proptosis
• Pain with eye movement

Risk factors for postseptal inflammation include:

• High neutrophil count
• Absence of infectious conjunctivitis
• Gross periorbital edema
• Age >3 years
• Previous antibiotic therapy 1

Treatment Algorithm

1. Outpatient Management (Mild Cases)

• Indicated when:

  • Eyelid <50% closed
  • No fever
  • Normal visual acuity
  • Normal extraocular movements
  • No proptosis

• Treatment:

  • High-dose amoxicillin-clavulanate for comprehensive coverage 1
  • Daily follow-up until definite improvement is noted
  • Duration: 5 days if clinical improvement occurs (as effective as 10-day course) 1

2. Inpatient Management (Moderate to Severe Cases)

• Indicated when:

  • Patient does not improve within 24-48 hours of outpatient therapy
  • Progressive infection
  • Proptosis present
  • Impaired visual acuity
  • Impaired and/or painful extraocular mobility
  • Systemic signs of infection (fever, elevated WBC)

• Treatment:

  • Hospitalization for intravenous antibiotics
  • Contrast-enhanced CT scan to evaluate for orbital involvement
  • Consultation with specialists (otolaryngology, ophthalmology) as needed 1

Antibiotic Selection

First-line therapy:

• High-dose amoxicillin-clavulanate (covers both streptococci and S. aureus) 1

Alternative options (for penicillin-allergic patients):

• Clindamycin (effective against streptococci and many S. aureus strains) 1
• For areas with high MRSA prevalence: consider adding coverage with trimethoprim-sulfamethoxazole or doxycycline 1

Adjunctive Measures

• Elevation of the affected area to promote gravity drainage of edema 1
• Treatment of predisposing factors (e.g., sinusitis, trauma site) 1
• Consider systemic corticosteroids in non-diabetic adult patients to hasten resolution 1

Monitoring and Follow-up

• Daily follow-up for outpatients until definite improvement
• If no improvement within 24-48 hours or worsening symptoms, hospitalize for IV antibiotics
• Watch for signs of orbital involvement (proptosis, limited eye movement, vision changes)
• Monitor for complications such as cavernous sinus thrombosis or intracranial extension 1

Common Pitfalls

1. Failing to distinguish between preseptal and orbital cellulitis, which require different management approaches
2. Inadequate follow-up of outpatient cases
3. Delayed recognition of progression to orbital cellulitis
4. Not considering MRSA in areas with high prevalence
5. Overlooking underlying sinusitis as a source of infection

Imaging (CT orbits with contrast) is not routinely needed for typical preseptal cellulitis but should be obtained if there are signs suggesting orbital involvement or if the patient fails to respond to initial therapy 1.