What is the recommended treatment for a patient with preseptal eyelid cellulitis?

Treatment of Preseptal Eyelid Cellulitis

For mild preseptal cellulitis without orbital involvement, initiate high-dose oral amoxicillin-clavulanate (80-90 mg/kg/day in children, standard adult dosing) with mandatory reassessment within 24-48 hours, while moderate-to-severe cases require hospitalization with intravenous broad-spectrum antibiotics. 1, 2, 3

Critical Initial Assessment: Rule Out Orbital Cellulitis

Before initiating treatment, you must distinguish preseptal from orbital cellulitis, as misdiagnosis can lead to permanent vision loss or death. 1, 3

Red flags requiring immediate hospitalization and IV antibiotics:

• Proptosis (forward displacement of the globe) 4, 1, 2
• Impaired or painful extraocular movements 4, 1, 2
• Decreased visual acuity or vision changes 4, 1, 2
• Ophthalmoplegia (paralysis of eye muscles) 4, 1, 2
• Severe headache or photophobia 2
• Movement restriction or diplopia 4

Preseptal cellulitis characteristics (infection anterior to orbital septum):

• Periorbital swelling, hyperemia, and edema confined to eyelids 3, 5
• No globe involvement or proptosis 3
• Normal extraocular movements 3
• Normal visual acuity 3

Outpatient Treatment Algorithm

Criteria for outpatient management (all must be met): 2, 3

• Eyelid less than 50% closed 2, 3
• No proptosis or visual changes 2, 3
• No impairment of extraocular movements 2
• No systemic signs of severe infection (fever >39°C, toxic appearance) 2
• Reliable follow-up available within 24-48 hours 2, 3

First-line oral antibiotic regimen:

• High-dose amoxicillin-clavulanate: 80-90 mg/kg/day (amoxicillin component) with 6.4 mg/kg/day clavulanate in 2 divided doses for children; 875 mg twice daily for adults 1, 2, 3
• Treatment duration: 5-7 days, extended if no improvement 1

Alternative oral regimens for penicillin allergy (non-type 1 hypersensitivity):

• Cefdinir, cefuroxime, or cefpodoxime 2
• Cephalexin or dicloxacillin 3
• Clindamycin (provides MRSA coverage) 3

Do NOT use trimethoprim/sulfamethoxazole or azithromycin due to high resistance rates. 2

Inpatient Treatment Algorithm

Criteria requiring hospitalization: 3

• Systemic signs of infection (high fever, toxic appearance) 3
• Eyelid more than 50% closed 3
• Inability to adequately examine the eye due to severe swelling 3
• Poor adherence to outpatient therapy anticipated 3
• Age <1 year (higher risk of rapid progression) 5

Intravenous antibiotic regimens:

• IV amoxicillin-clavulanate, cefazolin, or ceftriaxone for broad-spectrum Gram-positive coverage 3, 5
• Mean duration of IV antibiotics: 4 days hospitalization, then transition to oral for total 10 days 5

MRSA Coverage Considerations

Add MRSA-active antibiotics when risk factors present: 3

• Penetrating trauma or recent surgery 3, 6
• Purulent drainage 3
• Known MRSA colonization or previous MRSA infection 3
• Injection drug use 3

MRSA-active options:

• IV: vancomycin, daptomycin, or linezolid 3
• Oral: clindamycin, doxycycline, or trimethoprim-sulfamethoxazole 3

Imaging Indications

Obtain CT orbits with IV contrast when: 1, 3

• Any clinical suspicion of orbital involvement (proptosis, painful eye movements) 1, 3
• Failure to improve with antibiotics within 24-48 hours 3
• Inability to adequately examine the eye due to severe swelling 3
• Severe headache, photophobia, or neurologic findings suggesting intracranial extension 2
• High neutrophil count, gross periorbital edema, age >3 years, or previous antibiotic therapy 1

CT imaging differentiates preseptal from postseptal cellulitis, identifies abscess formation, and detects life-threatening complications including superior ophthalmic vein thrombosis, cavernous sinus thrombosis, or subdural empyema. 1, 3

Mandatory Follow-Up and Monitoring

Reassessment within 24-48 hours is non-negotiable for all outpatient cases. 1, 2, 3 Failure to improve or worsening symptoms requires immediate hospitalization and IV antibiotics. 2, 3

At follow-up, assess:

• Visual acuity 4
• Extraocular movements 4
• Degree of eyelid swelling 3
• Presence of proptosis 4
• Pupillary response (check for afferent pupillary defect) 4

Common Predisposing Factors and Special Considerations

Most common causes in hospitalized patients: 6

• Acute dacryocystitis (32.6%) 6
• Sinusitis/upper respiratory infection (28.8%) - particularly ethmoid sinusitis in children <5 years 2, 6
• Trauma or recent surgery (27.8%) 6

Surgical intervention may be necessary in 50% of hospitalized cases: 6

• Dacryocystorhinostomy/probing/stenting for dacryocystitis 6
• Abscess or chalazion drainage 6

Most common organisms recovered (when cultures obtained): 6

• Staphylococcus and Streptococcus species 6
• Haemophilus influenzae 6
• Klebsiella pneumoniae 6

Critical Pitfalls to Avoid

Delaying CT imaging when orbital signs present can lead to missed diagnosis of orbital cellulitis with catastrophic consequences including cavernous sinus thrombosis, meningitis, brain abscess, or death. 1

Starting corticosteroids before ophthalmology evaluation may worsen ocular conditions due to infection (e.g., herpetic keratitis/uveitis) or mask accurate diagnosis. 4

Inadequate follow-up after initiating outpatient therapy allows progression to orbital involvement - failure to reassess within 24-48 hours is unacceptable. 1, 2

Not considering MRSA coverage when risk factors present leads to inadequate treatment of methicillin-resistant Staphylococcus aureus infections. 1, 3

Prolonged eyelid occlusion in young children can cause occlusion amblyopia - monitor for squint development during and after treatment. 7

Puffy eyelids with pain, erythema, and systemic signs require urgent ophthalmology referral as this may indicate early progression requiring systemic antibiotics and specialist evaluation. 4