What is the treatment for orbital cellulitis?

Treatment of Orbital Cellulitis

The treatment for orbital cellulitis requires immediate initiation of broad-spectrum intravenous antibiotics with coverage for common causative organisms including Streptococcus pneumoniae, Haemophilus influenzae, Streptococcus pyogenes, Moraxella species, Staphylococcus aureus, and anaerobic bacteria. 1

Diagnosis and Classification

• Orbital cellulitis (postseptal) must be distinguished from preseptal cellulitis for appropriate management, as orbital cellulitis carries higher risks of serious complications including vision loss 2
• Clinical signs of orbital cellulitis include proptosis, limitation of extraocular movements, and possible visual compromise 2, 3
• CT scan of the orbits with IV contrast is the most useful initial imaging modality to differentiate preseptal from postseptal cellulitis and to identify potential complications such as orbital abscess 2
• MRI with contrast may be considered if intracranial complications are suspected or for more detailed assessment of intraorbital spread 2

Antibiotic Treatment

• Initiate empiric broad-spectrum IV antibiotics immediately after obtaining cultures 1
• First-line antibiotic regimens include:
  • High-dose amoxicillin-clavulanate IV 1, 4
  • Consider adding vancomycin for MRSA coverage, especially in areas with high MRSA prevalence 1, 5
  • Add clindamycin for anaerobic coverage when indicated 1
• Alternative options for patients with severe penicillin allergies include clindamycin or vancomycin 4
• Continue IV antibiotics until significant clinical improvement is observed, then transition to oral antibiotics to complete a total 10-14 day course 1

Surgical Management

• Surgical intervention is indicated for:
  • Subperiosteal or orbital abscess formation 2
  • Inadequate response to medical therapy within 24-48 hours 4
  • Progressive visual deterioration 6
  • Sinus drainage may be necessary when orbital cellulitis is secondary to sinusitis 3

Monitoring and Follow-up

• Daily assessment of visual acuity, pupillary reflexes, and extraocular movements is essential 1
• Obtain ophthalmology, otorhinolaryngology, and infectious disease consultations 1
• Monitor for potential complications including:
  • Vision loss due to ischemic optic neuropathy or central retinal artery occlusion 6
  • Cavernous sinus thrombosis 5
  • Intracranial extension (meningitis, brain abscess) 3, 5
  • Sepsis 3

Special Considerations

• Elevate the head of the bed to facilitate drainage of orbital edema 1
• For patients with suspected MRSA infection, ensure appropriate coverage with vancomycin, clindamycin, or trimethoprim-sulfamethoxazole 4, 5
• Children under 2 years of age with orbital cellulitis may have different causative organisms and presentation patterns compared to older children and adults 7
• Consider high-dose steroids in cases of severe orbital tension to prevent vision loss, but only after initiating appropriate antibiotic therapy 6

Common Pitfalls to Avoid

• Delaying imaging in patients with concerning features such as proptosis, visual changes, or ophthalmoplegia 4
• Failing to recognize the potential for rapid progression to vision-threatening complications, even in young, healthy individuals 5
• Not considering MRSA coverage when risk factors are present or in areas with high MRSA prevalence 4, 5
• Inadequate duration of therapy or failure to reassess response after initial treatment 4