What is the treatment for orbital cellulitis?

Treatment of Orbital Cellulitis

The treatment of orbital cellulitis requires immediate administration of broad-spectrum intravenous antibiotics with coverage for Streptococcus pneumoniae, Haemophilus influenzae, Streptococcus pyogenes, Moraxella spp, Staphylococcus aureus, and anaerobic bacteria, along with imaging to determine the extent of infection and potential complications. 1

Diagnosis and Classification

• Orbital cellulitis must be distinguished from preseptal cellulitis, as management and prognosis differ significantly 2
• CT scan of the orbits with IV contrast is the most useful initial imaging modality to differentiate preseptal from postseptal involvement and identify complications such as abscess formation 2
• Clinical indicators of orbital (postseptal) cellulitis include proptosis, limitation of extraocular movements, and possible vision compromise 2
• MRI with contrast is complementary to CT and should be considered when intracranial complications are suspected or for more detailed assessment of intraorbital spread 2

Initial Antibiotic Therapy

• Start broad-spectrum intravenous antibiotics immediately after obtaining blood cultures 1
• First-line antibiotic options include:
  • High-dose amoxicillin-clavulanate for comprehensive coverage 1, 3
  • Consider adding vancomycin if MRSA is suspected 1, 3
  • Add clindamycin for anaerobic coverage 1
• For patients with severe penicillin allergies, alternatives include clindamycin or vancomycin 3

Multidisciplinary Management

• Consult ophthalmology, otorhinolaryngology, and infectious disease specialists 1, 3
• Daily assessment of visual function and ocular movements is essential 1
• Elevate the head to facilitate drainage of edema 1

Surgical Intervention

• Surgical drainage is indicated for:
  • Orbital abscess formation
  • Significant sinus involvement requiring drainage
  • Poor response to initial medical therapy
  • Intracranial complications 4
• Endoscopic sinus drainage may be necessary when sinusitis (particularly ethmoid sinusitis) is the underlying cause 4, 5

Duration of Treatment and Follow-up

• Continue intravenous antibiotics until significant clinical improvement is observed 1
• Follow with oral antibiotics to complete a 10-14 day total course of treatment 1
• Regular follow-up is essential to ensure complete resolution and detect potential recurrence 1

Complications to Monitor

• Vision loss can occur due to ischemic optic neuropathy, central retinal artery occlusion, or increased orbital pressure 6, 5
• Intracranial complications include cavernous sinus thrombosis, meningitis, and cerebral abscess 7, 5
• Young, otherwise healthy individuals can still develop severe complications 7

Special Considerations

• Preseptal cellulitis cases may be managed on an outpatient basis with oral antibiotics if symptoms are mild 1, 3
• Children with orbital cellulitis most commonly have infection secondary to sinusitis, particularly ethmoid sinusitis 8, 4
• Polymicrobial infections are more common in individuals older than 15 years of age 5

Monitoring Response

• If no improvement is seen within 24-48 hours of initiating therapy, reassess diagnosis and consider surgical intervention 3
• Repeat imaging may be necessary if clinical deterioration occurs or to evaluate response to therapy 2