Treatment of Orbital Cellulitis
Orbital cellulitis requires immediate hospitalization with intravenous antibiotics and possible surgical intervention to prevent serious complications including vision loss, intracranial spread, and death. 1
Diagnosis and Classification
Orbital cellulitis must be distinguished from periorbital (preseptal) cellulitis:
Orbital cellulitis: Infection posterior to the orbital septum, characterized by:
- Proptosis
- Ophthalmoplegia (limited eye movement)
- Pain with eye movement
- Decreased visual acuity
- Chemosis (conjunctival swelling)
- Fever and systemic symptoms
Periorbital cellulitis: Infection anterior to the orbital septum, limited to the eyelids
Imaging (contrast-enhanced CT scan of orbits and sinuses) is essential for diagnosis and to identify complications such as subperiosteal or orbital abscesses 1, 2.
Treatment Algorithm
1. Initial Management
- Hospitalization is required for all cases of orbital cellulitis 1, 3
- Obtain imaging: Contrast-enhanced CT scan of orbits and sinuses to confirm diagnosis and identify abscesses 1
- Consultation: Ophthalmology, otolaryngology, and infectious disease specialists 1
2. Antimicrobial Therapy
Empiric IV antibiotics should be started immediately:
- First-line regimen: Vancomycin (to cover possible MRSA) plus one of the following:
This broad coverage is necessary as orbital cellulitis is often polymicrobial, with common pathogens including:
- Streptococcus pneumoniae
- Staphylococcus aureus (including MRSA)
- Nontypeable Haemophilus influenzae
- Streptococcus pyogenes
- Moraxella species
- Anaerobic bacteria
- In some cases, fungal pathogens (Aspergillus, zygomycetes) 1, 4, 2
3. Surgical Intervention
Surgical drainage is indicated for:
- Presence of abscess (subperiosteal or intraorbital)
- Deteriorating vision
- No improvement after 24-48 hours of IV antibiotics
- Progressive proptosis or ophthalmoplegia 1, 3, 2
Approximately 50% of patients with orbital cellulitis require surgical intervention 3.
4. Transition to Oral Therapy
- After clinical improvement (typically 3-5 days of IV therapy)
- Total duration of antibiotic therapy: 2-3 weeks
- Oral options include:
Special Considerations
Children
- More commonly caused by single organisms (S. aureus or Streptococcus species)
- Often associated with sinusitis, particularly ethmoid sinusitis 2
Adults
- More likely to have polymicrobial infections
- Higher risk of complications 2
Monitoring
- Daily ophthalmologic examinations to assess:
- Visual acuity
- Pupillary response
- Extraocular movements
- Degree of proptosis
Complications
Without prompt and appropriate treatment, orbital cellulitis can lead to:
Prevention of Recurrence
- Treat underlying sinusitis
- Address predisposing factors (dental infections, trauma)
- Complete the full course of antibiotics 1, 2
Orbital cellulitis represents a true ophthalmic emergency requiring aggressive management to prevent potentially devastating complications. The combination of prompt antimicrobial therapy and appropriate surgical intervention when indicated is essential for optimal outcomes.