What is the appropriate management for a pediatric patient presenting with periorbital edema (dark puffy under eyes)?

Management of Dark Puffy Under Eyes (Periorbital Edema) in Pediatric Patients

The most critical first step is to immediately distinguish between preseptal (periorbital) cellulitis and postseptal (orbital) cellulitis, as orbital cellulitis requires immediate hospitalization with IV antibiotics while preseptal cellulitis can often be managed outpatient. 1

Immediate Clinical Assessment

Look for these red flag features that indicate orbital cellulitis requiring immediate hospitalization: 1

• Proptosis (eye bulging forward)
• Impaired or painful extraocular movements
• Decreased visual acuity
• Ophthalmoplegia (paralysis of eye muscles)
• Eyelid more than 50% closed

If any of these features are present, this is orbital cellulitis and requires immediate hospitalization with IV antibiotics. 1

Diagnostic Algorithm Based on Clinical Presentation

If Infection is Suspected (red, warm, tender periorbital swelling):

Obtain CT orbits with IV contrast immediately if you suspect orbital involvement (proptosis, vision changes, ophthalmoplegia present). 2, 1 This imaging differentiates preseptal from postseptal cellulitis and identifies abscess formation or life-threatening complications including cavernous sinus thrombosis or subdural empyema. 2, 1

For mild preseptal cellulitis (no proptosis, normal vision, normal eye movements, eyelid <50% closed): 1

• Start high-dose amoxicillin-clavulanate orally 1
• Mandatory reassessment within 24-48 hours to ensure clinical improvement 1
• Treatment duration typically 5-7 days but extend if not improving 1
• Consider MRSA coverage (add trimethoprim-sulfamethoxazole or clindamycin) if risk factors present 1

For orbital cellulitis (any red flags present): 1

• Immediate hospitalization
• IV broad-spectrum antibiotics (vancomycin plus either ampicillin-sulbactam or ceftriaxone plus metronidazole) 1
• Immediate ophthalmology consultation 1
• Daily assessment of visual function and extraocular movements 1

If Trauma History is Present:

Refer immediately to a pediatric ophthalmologist for any child with blunt eye trauma and periorbital swelling. 2, 3 These children require comprehensive eye examination including visual acuity, funduscopic examination, and assessment for orbital floor fracture with potential muscle entrapment. 3 CT imaging may be needed to evaluate for orbital fractures and tissue entrapment. 3

If Chronic/Recurrent Swelling Without Infection Signs:

Consider these differential diagnoses based on associated features: 4

• Allergic conjunctivitis: Bilateral, itchy, watery discharge, seasonal pattern 5
• Nephrotic syndrome or renal disease: Bilateral, worse in morning, associated systemic symptoms 4
• Thyroid disease: Proptosis, lid retraction, may have systemic thyroid symptoms 4
• Inflammatory conditions (rare): Orofacial granulomatosis, rosacea (though extremely rare in children) 6, 7

Refer to pediatric ophthalmologist for: 2

• Children ≤7 years who are nonverbal or unable to read letters with suspected eye disease
• Any child with vision changes, severe refractive errors, or delayed visual milestones
• Ocular inflammation not responding to initial treatment within 3 weeks 2

If Associated with Eye Discharge/Crusting:

Bacterial conjunctivitis is highly likely if there is history of gluey/sticky eyelids plus mucoid or purulent discharge (96% positive predictive value). 8 In children, nontypeable Haemophilus influenzae accounts for 82% of bacterial conjunctivitis. 8

Treatment approach: 8

• Empirical topical antibiotic therapy is appropriate (erythromycin or polymyxin B-trimethoprim ophthalmic ointment)
• Warm compresses and eyelid hygiene 9
• If persistent beyond 3 weeks, refer to pediatric ophthalmologist 2

Critical Pitfalls to Avoid

Never delay CT imaging when proptosis, visual changes, or ophthalmoplegia are present - this can lead to catastrophic complications including vision loss, cavernous sinus thrombosis, meningitis, or death. 2, 1

Never discharge a child with preseptal cellulitis without arranging mandatory 24-48 hour follow-up - failure to reassess allows progression to orbital involvement. 1

Never assume bilateral periorbital edema is simply allergic - consider systemic causes including renal disease, especially if worse in the morning and associated with other systemic symptoms. 4

Never treat suspected orbital cellulitis as an outpatient - all cases require immediate hospitalization with IV antibiotics and ophthalmology consultation. 1