Treatment of Ocular Cellulitis
Ocular cellulitis requires prompt recognition and aggressive treatment with systemic antibiotics to prevent serious complications including vision loss and intracranial spread of infection. 1
Types and Clinical Presentation
Preseptal vs. Orbital Cellulitis
- Preseptal cellulitis: Infection anterior to the orbital septum
- Orbital (retroseptal) cellulitis: More serious infection involving orbital contents, characterized by:
- Limitation of eye movement
- Proptosis
- Pain with eye movement
- Decreased visual acuity
- Ophthalmoplegia
- Possible afferent pupillary defect
Common Causes
- Sinusitis (especially ethmoid sinusitis)
- Ocular infections (conjunctivitis, dacryocystitis)
- Trauma to eyelids
- Infected wounds
Diagnostic Evaluation
- Imaging: CT scan or orbital ultrasonography to differentiate preseptal from orbital cellulitis 1
- Laboratory tests:
- Complete blood count
- Blood cultures
- C-reactive protein
Treatment Algorithm
1. Immediate Systemic Antibiotic Therapy
For Preseptal Cellulitis (mild-moderate):
- First-line: Oral antibiotics
- Amoxicillin-clavulanate 875/125 mg twice daily for 5-10 days
- Alternative for penicillin-allergic patients: Clindamycin 300-450 mg three times daily
For Orbital Cellulitis or Severe Preseptal Cellulitis:
- First-line: Intravenous broad-spectrum antibiotics
- Cefotaxime + fosfomycin (may add an aminoglycoside like netromycin for severe cases) 1
- Alternative regimens:
- Vancomycin 15-20 mg/kg IV every 8-12 hours (if MRSA suspected)
- Ceftriaxone plus metronidazole (for coverage of anaerobes if sinusitis-related)
2. Duration of Treatment
- IV antibiotics: Typically 3-7 days until clinical improvement 1
- Transition to oral antibiotics: After clinical improvement
- Amoxicillin-clavulanate or pristinamycin for total duration of 10-14 days 1
3. Surgical Intervention
- Indications for surgical drainage/decompression:
- Subperiosteal or orbital abscess
- Failure to respond to antibiotics within 24-48 hours
- Worsening vision
- Increasing proptosis
- Central retinal artery occlusion (rare but serious complication) 2
4. Monitoring and Follow-up
- Reassessment within 24-48 hours of initiating therapy
- Monitor for:
- Improvement in eyelid swelling and erythema
- Reduction in pain
- Improved eye movements
- Stable or improving visual acuity
Special Considerations
Pediatric Patients
- More common in children
- Good prognosis with appropriate antibiotic therapy 1
- Multidisciplinary management recommended for orbital involvement
MRSA Coverage
- Consider MRSA coverage if:
- Prior MRSA infection
- Failure to respond to beta-lactam therapy within 48-72 hours
- High local prevalence of community-acquired MRSA
Complications to Monitor
- Vision loss
- Cavernous sinus thrombosis
- Superior ophthalmic vein thrombosis 3
- Intracranial extension (meningitis, brain abscess)
- Central retinal artery occlusion 2
Prevention of Recurrence
- Treat underlying conditions:
- Chronic sinusitis
- Dacryocystitis
- Dental infections
Early recognition and aggressive treatment are essential to prevent vision-threatening and life-threatening complications of ocular cellulitis. Patients with orbital involvement require hospitalization and multidisciplinary management.