What are the treatment options for a patient with a history of macular degeneration and glaucoma presenting with red streaking around the lateral canthus?

Red Streaking Around the Lateral Canthus: Preseptal or Periorbital Cellulitis

This patient requires immediate treatment with systemic antibiotics for presumed preseptal cellulitis, as red streaking suggests lymphangitic spread of infection that could progress to orbital cellulitis or systemic sepsis. While the patient's history of macular degeneration and glaucoma is important for ongoing ophthalmologic care, these chronic conditions do not alter the acute management of what appears to be a bacterial skin/soft tissue infection.

Immediate Management

Clinical Assessment Priority

• Urgent ophthalmologic examination is required to distinguish preseptal cellulitis (infection anterior to the orbital septum) from orbital cellulitis (infection posterior to the septum), as the American Academy of Ophthalmology emphasizes that symptoms of pain and visual disturbance require immediate specialist assessment to prevent severe visual morbidity 1
• Visual acuity testing, pupil examination, extraocular motility assessment, and intraocular pressure measurement must be performed immediately, as these baseline measurements help differentiate preseptal from orbital involvement 1
• Red streaking (lymphangitis) indicates active bacterial spread and represents a medical urgency requiring same-day treatment initiation

Key Distinguishing Features to Assess

• Proptosis, ophthalmoplegia, or decreased vision would indicate orbital involvement requiring IV antibiotics and possible surgical intervention 1
• Pain with eye movement or relative afferent pupillary defect suggests posterior extension beyond the orbital septum 1
• Elevated intraocular pressure could indicate angle-closure crisis (given the glaucoma history) rather than or in addition to infection, requiring immediate pressure-lowering therapy 1

Antibiotic Treatment

For Preseptal Cellulitis (No Orbital Signs)

• Oral antibiotics covering Staphylococcus aureus and Streptococcus species are first-line for preseptal cellulitis without orbital involvement
• Common regimens include cephalexin 500mg four times daily or amoxicillin-clavulanate 875mg twice daily for 7-10 days
• MRSA coverage with trimethoprim-sulfamethoxazole or doxycycline should be added if risk factors present (recent hospitalization, known MRSA colonization, treatment failure)

For Orbital Cellulitis (If Present)

• Immediate hospitalization with IV antibiotics (vancomycin plus ceftriaxone or piperacillin-tazobactam) is mandatory
• Emergent CT imaging of orbits and sinuses to assess for abscess formation requiring surgical drainage

Considerations for Glaucoma and Macular Degeneration

Glaucoma Management During Acute Infection

• Continue current glaucoma medications unless contraindicated by systemic antibiotic therapy 2, 3
• Monitor intraocular pressure closely during the infection, as inflammation can cause pressure elevation 2
• Avoid systemic corticosteroids if possible, as they can elevate intraocular pressure in glaucoma patients 2

Macular Degeneration Considerations

• The infection does not directly affect AMD management, but ensure the patient continues AREDS2 supplementation if prescribed 2
• Postpone any scheduled anti-VEGF injections until the periocular infection has completely resolved to avoid introducing infection into the eye 2

Critical Pitfalls to Avoid

• Do not dismiss red streaking as minor - lymphangitic spread indicates aggressive infection requiring systemic antibiotics, not just topical therapy
• Do not use topical antibiotics alone (such as erythromycin 4 or bacitracin 5) for periorbital cellulitis with lymphangitic spread, as these are insufficient for deep tissue infection
• Do not delay ophthalmologic evaluation - the American Academy of Ophthalmology emphasizes that delaying treatment for vision-threatening conditions can result in permanent visual loss 1
• Do not assume the glaucoma or AMD are related to the red streaking - these are chronic conditions while the streaking represents acute bacterial infection

Follow-Up Protocol

• Re-examine within 24-48 hours to ensure clinical improvement on antibiotics
• Immediate return if worsening (increased pain, vision changes, proptosis, fever) suggesting progression to orbital cellulitis
• Resume routine glaucoma and AMD monitoring once infection resolves, as patients with glaucoma require regular IOP monitoring and visual field testing 2, 3, and AMD patients need ongoing assessment for disease progression 2