What is the recommended management for orbital cellulitis?

Management of Orbital Cellulitis

The recommended management for orbital cellulitis consists of prompt administration of broad-spectrum intravenous antibiotics, imaging to assess for complications, and early ophthalmology consultation, with surgical intervention reserved for cases with abscess formation or inadequate response to medical therapy. 1

Diagnosis and Initial Assessment

• Orbital cellulitis is defined as infection of the globe and surrounding soft tissues posterior to the orbital septum

• Clinical presentation includes:

  • Eyelid edema and erythema
  • Chemosis (conjunctival swelling)
  • Proptosis
  • Restricted or painful extraocular movements
  • Vision changes
  • Fever and systemic symptoms 1, 2

• Imaging is crucial for diagnosis and evaluation of complications:

  • CT scan of brain and orbits with and without contrast is the first-line imaging modality
  • MRI should be performed if CT is non-diagnostic
  • Imaging helps identify complications such as subperiosteal abscess or intracranial extension 1

Antibiotic Therapy

First-line Treatment

• Broad-spectrum intravenous antibiotics should be initiated promptly
• While no specific guidelines exist for orbital cellulitis, recommended regimens include:
  • Adults: Vancomycin plus a third-generation cephalosporin with anaerobic coverage
  • Children under 6 years: Cefuroxime 3
  • Children over 6 years: Cloxacillin and chloramphenicol 3

Alternative Approaches

• Recent research suggests that oral ciprofloxacin and clindamycin combination may be as effective as IV therapy in selected cases, offering advantages of rapid delivery and simplified administration, particularly in children 4
• However, this approach should be reserved for less severe cases and under close monitoring

Antibiotic Selection Considerations

• Staphylococcus aureus is the most commonly isolated pathogen 5
• Bacterial susceptibility testing has shown high resistance to penicillin G and ampicillin
• Amikacin and vancomycin demonstrated no resistance in susceptibility tests 5

Surgical Management

• Surgical intervention is indicated for:

  • Subperiosteal or orbital abscess
  • Inadequate response to medical therapy within 24-48 hours
  • Visual deterioration
  • Orbital compartment syndrome 1, 2

• CT evidence of subperiosteal abscess alone is not an absolute indication for surgical drainage; clinical response to antibiotics should guide management 3

Monitoring and Follow-up

• Daily ophthalmologic examinations to assess:

  • Visual acuity
  • Pupillary responses
  • Extraocular movements
  • Proptosis
  • Intraocular pressure

• Transition from IV to oral antibiotics can be considered when:

  • Clinical improvement is evident
  • Patient is afebrile for 24-48 hours
  • Inflammatory markers are decreasing

Special Considerations

• Orbital compartment syndrome is a sight-threatening emergency requiring immediate lateral canthotomy and cantholysis 1
• Intracranial complications (cavernous sinus thrombosis, meningitis, brain abscess) require neurosurgical consultation 1
• The use of corticosteroids remains controversial and should be discussed with specialists 1

Common Pitfalls to Avoid

• Delaying antibiotic administration while waiting for imaging
• Failing to distinguish between preseptal and orbital cellulitis
• Overlooking potential complications such as intracranial extension
• Inadequate follow-up during antibiotic therapy

The management of orbital cellulitis has improved significantly with early diagnosis, appropriate antibiotics, and timely surgical intervention when indicated, resulting in reduced visual morbidity compared to the pre-antibiotic era 2.