Treatment of Preseptal (Periorbital) Cellulitis
For preorbital swelling and inflammation without sepsis, initiate high-dose oral amoxicillin-clavulanate as outpatient therapy with mandatory reassessment within 24-48 hours to ensure clinical improvement and rule out progression to orbital cellulitis. 1
Immediate Clinical Assessment
Before initiating treatment, you must distinguish preseptal from orbital cellulitis, as the latter requires immediate hospitalization and IV antibiotics. 1, 2
Critical features indicating orbital (postseptal) involvement requiring urgent imaging and hospitalization:
- Proptosis (forward displacement of the eye) 3, 1, 2
- Impaired or painful extraocular movements 3, 1, 2
- Decreased visual acuity 1, 2
- Ophthalmoplegia 3, 1
Features consistent with preseptal cellulitis (safe for outpatient management):
- Diffuse periorbital erythema and edema without clear borders 2
- Warmth and tenderness across the eyelid and periorbital tissues 2
- Eyelid less than 50% closed 1
- Normal extraocular movements and preserved vision 2
- No proptosis 2
Outpatient Treatment Protocol
First-line antibiotic therapy:
- High-dose amoxicillin-clavulanate is the recommended oral antibiotic, providing comprehensive coverage against Streptococcus pneumoniae, Haemophilus influenzae, Streptococcus pyogenes, Moraxella species, and anaerobic bacteria. 1
Treatment duration:
- Typically 5-7 days, but extend if infection has not improved at reassessment. 1
Mandatory follow-up:
- Reassess within 24-48 hours to ensure clinical improvement. 1, 2
- Failure to improve or any development of orbital signs requires immediate CT imaging and hospitalization. 1, 2
When to Obtain Imaging
CT orbits with IV contrast is indicated if:
- Clinical findings cannot reliably distinguish preseptal from orbital cellulitis 2
- Any signs of orbital involvement develop (proptosis, impaired eye movements, vision changes) 2
- No improvement after 24-48 hours of antibiotics 2
- Eyelid more than 50% closed 1
- Systemic signs of infection present 1
The American College of Radiology emphasizes that CT with contrast is the most useful initial imaging to differentiate preseptal from postseptal disease and identify life-threatening complications including superior ophthalmic vein thrombosis, cavernous sinus thrombosis, or subdural empyema. 1
Criteria Requiring Immediate Hospitalization
Admit for IV antibiotics if:
- Eyelid more than 50% closed 1
- Systemic signs of infection present (fever, elevated white blood cell count) 1
- Inability to adequately examine the eye 1
- Unreliable follow-up 1
- Any orbital signs develop 1
Critical Pitfalls to Avoid
Delaying imaging when orbital signs are present can lead to vision loss, cavernous sinus thrombosis, meningitis, brain abscess, or death. 3, 1 Any proptosis, impaired extraocular movements, decreased visual acuity, or ophthalmoplegia mandates immediate CT imaging. 1, 2
Inadequate follow-up after initiating outpatient therapy allows progression to orbital involvement. 1 The 24-48 hour reassessment is not optional—it is mandatory to catch early progression. 1
Assuming all periorbital swelling is infectious can miss inflammatory conditions like idiopathic orbital inflammatory syndrome (IOIS) or IgG4-related orbital disease, which require corticosteroids rather than antibiotics. 3 However, these conditions typically present with more severe orbital signs and are diagnoses of exclusion. 3
Not considering MRSA coverage when risk factors are present (recent hospitalization, IV drug use, known MRSA colonization) can lead to treatment failure. 1 In such cases, add trimethoprim-sulfamethoxazole or doxycycline to the regimen. 1
Confusing preseptal cellulitis with a simple stye (hordeolum) leads to unnecessary antibiotic use. 2 A stye presents as a localized, well-defined nodule with induration and erythema limited to the defined area of the abscess, treated with warm compresses and incision/drainage if needed—not antibiotics. 2