What is the recommended treatment for cellulitis around the eye?

Periorbital vs. Orbital Cellulitis: Critical Distinction and Management

Cellulitis around the eye requires immediate differentiation between preseptal (periorbital) and postseptal (orbital) cellulitis, as they represent distinct entities with dramatically different management approaches and complication risks. 1, 2

Initial Assessment: Preseptal vs. Postseptal

Examine specifically for:

• Proptosis (forward displacement of the eyeball) 1
• Impaired or painful extraocular movements 1
• Impaired visual acuity 1
• Degree of eyelid closure (>50% closure suggests more severe disease) 1

If ANY of these postseptal signs are present, this is orbital cellulitis requiring hospitalization. 1

Preseptal (Periorbital) Cellulitis Management

Mild Cases (Eyelid <50% Closed)

Treat as outpatient with oral antibiotics covering streptococci and methicillin-sensitive S. aureus: 1

• High-dose amoxicillin-clavulanate (875/125 mg twice daily for adults) provides comprehensive single-agent coverage 1, 3
• Alternative oral agents: cephalexin 500 mg every 6 hours, dicloxacin, or clindamycin 300-450 mg every 6 hours 3, 4
• Duration: 5 days if clinical improvement occurs; extend only if symptoms persist 5, 3

Mandatory daily follow-up until definite improvement is documented. 1

Moderate Cases or Lack of Improvement at 24-48 Hours

Hospitalize and initiate IV antibiotics if: 1

• No improvement within 24-48 hours of oral therapy
• Progressive infection despite treatment
• Eyelid closure >50%
• Patient unable to follow up reliably

Postseptal (Orbital) Cellulitis Management

Immediate Actions

All patients with orbital cellulitis require hospitalization and IV antibiotics. 1, 2

Obtain contrast-enhanced CT scan (preferably coronal thin-cut) of head, orbits, and sinuses immediately to assess for: 1

• Subperiosteal abscess
• Orbital abscess
• Intracranial extension

IV Antibiotic Regimen

First-line therapy: 1

• Vancomycin 15-20 mg/kg IV every 8-12 hours (to cover possible methicillin-resistant S. pneumoniae and MRSA) 1, 5
• PLUS high-dose amoxicillin-clavulanate or cefotaxime for comprehensive coverage 1, 6

Alternative regimens for severe cases with systemic toxicity: 5

• Vancomycin PLUS piperacillin-tazobactam 3.375-4.5 g IV every 6 hours
• Vancomycin PLUS a carbapenem

Multidisciplinary Consultation

Obtain immediate consultation with: 1

• Otolaryngology (for sinus source and potential surgical drainage)
• Ophthalmology (for vision monitoring and orbital assessment)
• Infectious disease (for antibiotic selection and duration)

Surgical Intervention Indications

Surgical drainage is necessary in approximately 49% of orbital cellulitis cases when: 2

• Subperiosteal or orbital abscess is identified on imaging
• Progressive infection despite 24-48 hours of appropriate IV antibiotics
• Vision deterioration
• Complete ophthalmoplegia

Pediatric Considerations

Children under 2 years with preseptal cellulitis often have associated ocular infection (conjunctivitis or dacryocystitis) rather than sinusitis. 6

For hospitalized children with orbital cellulitis: 1

• Vancomycin 15 mg/kg IV every 6 hours
• PLUS cefotaxime or ceftriaxone for comprehensive coverage
• Mean IV treatment duration: 3 days, followed by oral amoxicillin-clavulanate 6

Oral Antibiotic Option for Selected Cases

Emerging evidence suggests oral ciprofloxacin plus clindamycin may be as effective as IV therapy for orbital cellulitis in carefully selected patients (mean hospital stay 4.4 days, no complications in 19 patients). 7 However, this approach should only be considered in:

• Patients without severe systemic toxicity
• Close monitoring capability
• No evidence of abscess formation

This contradicts traditional management and should be reserved for specialized centers with experience in this approach. 7

Critical Pitfalls to Avoid

• Never treat orbital cellulitis with oral antibiotics alone as initial therapy unless in a specialized center with proven protocols 1, 2
• Do not delay CT imaging if any postseptal signs are present 1
• Do not use beta-lactam monotherapy without MRSA coverage for orbital cellulitis, as methicillin-resistant organisms are a concern 1
• Do not assume improvement means cure—orbital cellulitis has a 23% complication rate including vision loss, cavernous sinus thrombosis, and intracranial extension 2

Underlying Etiology

Orbital cellulitis is most commonly secondary to acute ethmoiditis in young children, while frontal sinusitis predominates in adolescents. 1 Address the underlying sinus infection definitively to prevent recurrence.