Orbital Cellulitis Management

Algorithm Steps

1. ▶

   Start

   Suspected Orbital/Periorbital Infection

   Periorbital erythema, edema, warmth. Often associated with sinusitis, trauma, or skin infection

   1. ◆

      Decision

      Signs of Orbital (Postseptal) Involvement?

      Key distinguishing features: proptosis, ophthalmoplegia, pain with eye movement, vision changes, RAPD

      1. ●

         Action

         Preseptal Cellulitis

         Infection anterior to orbital septum only

         • Lid swelling, erythema
         • NO proptosis, NO ophthalmoplegia
         • Vision normal, pupils normal
         • May be managed as outpatient if mild
         1. ●

            Action

            Preseptal Treatment

            Oral antibiotics if mild, IV if severe/young child

            • ORAL: Amoxicillin-clavulanate 875/125mg BID
            • OR Clindamycin + TMP-SMX if MRSA concern
            • PEDIATRIC IV: Ceftriaxone 50mg/kg/day
            • Add vancomycin if MRSA suspected
            • Duration: 7-10 days oral (or until resolution)
            1. ◆

               Decision

               Clinical Response at 24-48 hours?

               Assess: lid swelling, proptosis, vision, EOM, fever

               1. ●

                  Action

                  Continue IV Antibiotics

                  Clinical improvement - continue current regimen

                  • Total IV course usually 7-14 days
                  • Transition to PO when clinically improved
                  • Amoxicillin-clavulanate PO to complete 2-3 weeks total
                  1. ⚠

                     Warning

                     ⚠️ Watch for Complications

                     Life and vision-threatening sequelae possible

                     • Cavernous sinus thrombosis (bilateral signs, CN palsies)
                     • Meningitis, subdural/brain abscess
                     • Optic neuropathy, vision loss
                     • Sepsis
                     1. ✓

                        Outcome

                        Infection Resolved

                        Complete antibiotic course, follow up for any residual sinusitis

                     2. ✓

                        Outcome

                        Surgical Drainage

                        Abscess drainage, sinus surgery as indicated. Continue IV antibiotics post-op

               2. ●

                  Action

                  Surgical Evaluation

                  ENT and/or Ophthalmology consultation for drainage

                  • Indications: no improvement 48h IV antibiotics
                  • Subperiosteal/orbital abscess >10mm
                  • Optic nerve compromise
                  • Evidence of gas in abscess (anaerobic)
                  • Intracranial extension
      2. ●

         Action

         Orbital Cellulitis - EMERGENCY

         Infection posterior to orbital septum

         • Proptosis present
         • Pain with eye movement
         • Ophthalmoplegia (limited EOM)
         • May have vision loss, RAPD
         • Fever common, leukocytosis ~75%
         1. ●

            Action

            CT Orbits/Sinuses/Brain

            URGENT imaging for all suspected orbital cellulitis

            • Thin axial and coronal cuts without contrast
            • Include orbits, paranasal sinuses, frontal lobes
            • Look for: subperiosteal abscess, fat stranding, intracranial extension
            • MRI if intracranial complication suspected
            1. ●

               Action

               Chandler Classification

               Stage severity to guide management

               • Stage I: Preseptal cellulitis
               • Stage II: Orbital cellulitis (no abscess)
               • Stage III: Subperiosteal abscess
               • Stage IV: Orbital abscess
               • Stage V: Cavernous sinus thrombosis
               1. ●

                  Action

                  Orbital Cellulitis - IV Antibiotics

                  ADMISSION REQUIRED for IV antibiotics

                  • Ceftriaxone 2g IV q24h (or cefotaxime)
                  • PLUS Metronidazole 500mg IV q8h (anaerobic coverage)
                  • OR Clindamycin 600-900mg IV q8h (alternative for anaerobes)
                  • ADD Vancomycin 15-20mg/kg IV q8-12h if MRSA risk
                  • Nasal decongestants for associated sinusitis