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Orbital Cellulitis Treatment & Management

  • Author: John N Harrington, MD, FACS; Chief Editor: Edsel Ing, MD, FRCSC  more...
 
Updated: Mar 11, 2016
 

Approach Considerations

The patient with orbital cellulitis should be promptly hospitalized for treatment, with hospitalization continuing until the patient is afebrile and has clearly improved clinically. Historically, the presence of subperiosteal or intraorbital abscess was an indication for surgical drainage in addition to antibiotic therapy. However, medical management alone can be successful in some patients without visual loss, especially those with small (<500 mm³), medially located, pediatric subperiosteal abscess.[16, 17, 18]

Surgery

Canthotomy and cantholysis should be performed on an emergency basis if an orbital compartment syndrome is diagnosed at any point in the course of the disease.

Consider surgical drainage if the response to appropriate antibiotic therapy has been poor within 24-48 hours, if the CT scan shows the sinuses to be completely opacified, if the patient has an intraorbital abscess, or if there is a large subperiosteal abscess, especially in an adult. The drains should be left in place for several days. Repeat surgical drainage may be required. In cases of fungal infection, surgical debridement of the orbit is indicated and may require exenteration of the orbit and the sinuses. 

Consultations

Ear, nose, and throat (ENT) consultation is required for cases of orbital cellulitis arising from sinus disease. Consult other specialists such as pediatricians, infectious disease specialists, and radiologists, as indicated. Neurosurgical consultation is indicated if brain abscesses appear.

Transfer

If necessary, the patient may be transferred for further diagnostic evaluation or for surgical intervention.

Deterrence/prevention

No foolproof method for the prevention of orbital cellulitis exists; however, proper treatment of conditions that may precipitate orbital cellulitis (eg, preseptal cellulitis, sinusitis, dental disease) is the best deterrent.

Diet

No special dietary requirements are indicated other than adequate hydration of the patient.

Follow-up

Patients are ideally monitored by an ophthalmologist, ENT specialist, and infectious disease specialist until symptoms, fever, WBC count, and imaging confirm that antibiotics can be discontinued.

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Inpatient Care

Closely monitor the patient at least daily, with vision reevaluated by standardized vision testing, preferably by the same examiner, as appropriate. Evaluate the antibiotic coverage daily and change it as needed, depending on the results of cultures and the patient's clinical course.[19] Repeat CT scans if the patient's condition worsens or does not respond to appropriate antibiotics.

Once the patient is clearly improving and has been afebrile for at least 48 hours, he or she can be changed from IV antibiotics to oral antibiotics (eg, amoxicillin clavulanate, ampicillin, cefpodoxime, cefuroxime, cefprozil) for aerobic infections or to metronidazole for anaerobic infections.

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Pharmacologic Therapy

Medical care of orbital cellulitis consists of the proper use of the appropriate antibiotics. Broad-spectrum IV antibiotics should be started immediately and continued until the choice of antibiotics can be tailored for specifically identified pathogens identified on cultures. Typically, IV antibiotic therapy should be continued for 1-2 weeks and then followed by oral antibiotics for an additional 2-3 weeks. Fungal infection requires IV antifungal therapy along with surgical debridement.

Regarding pediatric care, a study by Emmett et al found that the length of IV therapy associated with successful nonsurgical management of children with subperiosteal abscess was considerably shorter than the length of time normally recommended in pediatric infectious disease literature. This result suggested that clinical judgment regarding each patient’s initial CT scan findings and evolving signs, symptoms, and laboratory profile should be taken into account when scheduling IV intervals.[20]

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Indications for Surgical Drainage

Surgical drainage of an orbital abscess is indicated in any of the following instances:

  • A decrease in vision occurs
  • An afferent pupillary defect develops
  • Proptosis progresses despite appropriate antibiotic therapy
  • The size of the abscess does not reduce on CT scan within 48-72 hours after appropriate antibiotics have been administered; if brain abscesses develop and do not respond to antibiotic therapy, craniotomy is indicated.
  • The presence of a drainable fluid collection is evident on CT scan in patients older than 16 years
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Contributor Information and Disclosures
Author

John N Harrington, MD, FACS Director of Ophthalmic Plastic and Reconstructive Surgery, Department of Ophthalmology, Baylor University Medical Center; Clinical Professor Emeritus, Department of Ophthalmology, University of Texas Southwestern Medical Center at Dallas, Southwestern Medical School

John N Harrington, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Texas Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Edsel Ing, MD, FRCSC Associate Professor, Department of Ophthalmology and Vision Sciences, University of Toronto Faculty of Medicine; Consulting Staff, Hospital for Sick Children and Sunnybrook Hospital

Edsel Ing, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Society of Ophthalmic Plastic and Reconstructive Surgery, Royal College of Physicians and Surgeons of Canada, Canadian Ophthalmological Society, North American Neuro-Ophthalmology Society, Canadian Society of Oculoplastic Surgery, European Society of Ophthalmic Plastic and Reconstructive Surgery, Canadian Medical Association, Ontario Medical Association, Statistical Society of Canada, Chinese Canadian Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

Brian A Phillpotts, MD Former Vitreo-Retinal Service Director, Former Program Director, Clinical Assistant Professor, Department of Ophthalmology, Howard University College of Medicine

Brian A Phillpotts, MD is a member of the following medical societies: American Academy of Ophthalmology, American Diabetes Association, American Medical Association, and National Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
  1. Anari S, Karagama YG, Fulton B, et al. Neonatal disseminated methicillin-resistant Staphylococcus aureus presenting as orbital cellulitis. J Laryngol Otol. 2005 Jan. 119(1):64-7. [Medline].

  2. Babar TF, Zaman M, Khan MN, Khan MD. Risk factors of preseptal and orbital cellulitis. J Coll Physicians Surg Pak. 2009 Jan. 19(1):39-42. [Medline].

  3. Bergin DJ, Wright JE. Orbital cellulitis. Br J Ophthalmol. 1986 Mar. 70(3):174-8. [Medline].

  4. Blomquist PH. Methicillin-resistant Staphylococcus aureus infections of the eye and orbit (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc. 2006. 104:322-45. [Medline].

  5. Boden JH, Ainbinder DJ. Methicillin-resistant ascending facial and orbital cellulitis in an operation Iraqi Freedom troop population. Ophthal Plast Reconstr Surg. 2007 Sep-Oct. 23(5):397-9. [Medline].

  6. Bullock JD, Fleishman JA. Orbital cellulitis following dental extraction. Trans Am Ophthalmol Soc. 1984. 82:111-33. [Medline].

  7. Chiu ES, Capel B, Press R, et al. Successful management of orbital cellulitis and temporary visual loss after blepharoplasty. Plast Reconstr Surg. 2006 Sep. 118(3):67e-72e. [Medline].

  8. Denning DW, Stevens DA. Antifungal and surgical treatment of invasive aspergillosis: review of 2,121 published cases. Rev Infect Dis. 1990 Nov-Dec. 12(6):1147-201. [Medline].

  9. Dortzbach RK, Segrest DR. Orbital aspergillosis. Ophthalmic Surg. 1983 Mar. 14(3):240-4. [Medline].

  10. Doxanas MT, Anderson RL. Clinical Orbital Anatomy. Baltimore, Md: Williams & Wilkins. 1984.

  11. Emmett Hurley P, Harris GJ. Subperiosteal abscess of the orbit: duration of intravenous antibiotic therapy in nonsurgical cases. Ophthal Plast Reconstr Surg. 2012 Jan. 28(1):22-6. [Medline].

  12. Ferry AP, Abedi S. Diagnosis and management of rhino-orbitocerebral mucormycosis (phycomycosis). A report of 16 personally observed cases. Ophthalmology. 1983 Sep. 90(9):1096-104. [Medline].

  13. Garcia GH, Harris GJ. Criteria for nonsurgical management of subperiosteal abscess of the orbit: analysis of outcomes 1988-1998. Ophthalmology. 2000 Aug. 107(8):1454-6; discussion 1457-8. [Medline].

  14. Gass JD. Ocular manifestations of acute mucormycosis. Arch Ophthalmol. 1961 Feb. 65:226-37. [Medline].

  15. Grimes D, Fan K, Huppa C. Case report: dental infection leading to orbital cellulitis. Dent Update. 2006 May. 33(4):217-8, 220. [Medline].

  16. Harris GJ. Subperiosteal abscess of the orbit. Arch Ophthalmol. 1983 May. 101(5):751-7. [Medline].

  17. Harris GJ. Subperiosteal inflammation of the orbit. A bacteriological analysis of 17 cases. Arch Ophthalmol. 1988 Jul. 106(7):947-52. [Medline].

  18. Liao JC, Harris GJ. Subperiosteal abscess of the orbit: evolving pathogens and the therapeutic protocol. Ophthalmology. 2015 Mar. 122 (3):639-47. [Medline].

  19. Harris GJ, Will BR. Orbital aspergillosis. Conservative debridement and local amphotericin irrigation. Ophthal Plast Reconstr Surg. 1989. 5(3):207-11. [Medline].

  20. Hollsten J, Hollsten D, Green, MK. Orbital community-acquired methicillin-resistant Staphylococcus aureus infections: the range of presentation, increasing prevalence and efficacy of treatment. Poster at Fall Scientific Symposium, American Society of Ophthalmic Plastic and Reconstructive Surgery. Nov 2008.

  21. Hornblass A, Herschorn BJ, Stern K, et al. Orbital abscess. Surv Ophthalmol. 1984 Nov-Dec. 29(3):169-78. [Medline].

  22. Jackson K, Baker SR. Clinical implications of orbital cellulitis. Laryngoscope. 1986 May. 96(5):568-74. [Medline].

  23. Jones DB, Steinkuller PG. Strategies for the initial management of acute preseptal and orbital cellulitis. Trans Am Ophthalmol Soc. 1988. 86:94-108; discussion 108-12. [Medline].

  24. Jordan DR, St Onge P, Anderson RL, et al. Complications associated with alloplastic implants used in orbital fracture repair. Ophthalmology. 1992 Oct. 99(10):1600-8. [Medline].

  25. Kloek CE, Rubin PA. Role of inflammation in orbital cellulitis. Int Ophthalmol Clin. 2006 Spring. 46(2):57-68. [Medline].

  26. Koornneef L. Orbital septa: anatomy and function. Ophthalmology. 1979 May. 86(5):876-80. [Medline].

  27. Lemke BN, Gonnering RS, Weinstein JM. Orbital cellulitis with periosteal elevation. Ophthal Plast Reconstr Surg. 1987. 3(1):1-7. [Medline].

  28. Mauriello JA Jr, Hargrave S, Yee S, et al. Infection after insertion of alloplastic orbital floor implants. Am J Ophthalmol. 1994 Feb 15. 117(2):246-52. [Medline].

  29. McKinley SH, Yen MT, Miller AM, et al. Microbiology of pediatric orbital cellulitis. Am J Ophthalmol. 2007 Oct. 144(4):497-501. [Medline].

  30. Nageswaran S, Woods CR, Benjamin DK Jr, et al. Orbital cellulitis in children. Pediatr Infect Dis J. 2006 Aug. 25(8):695-9. [Medline].

  31. Rutar T, Chambers HF, Crawford JB, et al. Ophthalmic manifestations of infections caused by the USA300 clone of community-associated methicillin-resistant Staphylococcus aureus. Ophthalmology. 2006 Aug. 113(8):1455-62. [Medline].

  32. Rutar T, Zwick OM, Cockerham KP, et al. Bilateral blindness from orbital cellulitis caused by community-acquired methicillin-resistant Staphylococcus aureus. Am J Ophthalmol. 2005 Oct. 140(4):740-2. [Medline].

  33. Schramm VL Jr, Curtin HD, Kennerdell JS. Evaluation of orbital cellulitis and results of treatment. Laryngoscope. 1982 Jul. 92(7 Pt 1):732-8. [Medline].

  34. Shields JA, Shields CL, Suvarnamani C, et al. Retinoblastoma manifesting as orbital cellulitis. Am J Ophthalmol. 1991 Oct 15. 112(4):442-9. [Medline].

  35. Sridhara SR, Paragache G, Panda NK, et al. Mucormycosis in immunocompetent individuals: an increasing trend. J Otolaryngol. 2005 Dec. 34(6):402-6. [Medline].

  36. Steinkuller PG, Jones DB. Microbial preseptal and orbital cellulitis. Tasman W, ed. Clinical Ophthalmology. Philadelphia, Pa: Lippincott, Williams & Wilkins; 1999. 1-8, 17-29, Chap 25.

  37. Vayalumkal JV, Jadavji T. Children hospitalized with skin and soft tissue infections: a guide to antibacterial selection and treatment. Paediatr Drugs. 2006. 8(2):99-111. [Medline].

  38. Westley GJ, Mazur JM, Sifton DW, eds. Physicians' Desk Reference. Montvale, NJ: Medical Economics Co; 1998. Vol 52: 2081, 2145.

  39. Yen MT, Yen KG. Effect of corticosteroids in the acute management of pediatric orbital cellulitis with subperiosteal abscess. Ophthal Plast Reconstr Surg. 2005 Sep. 21(5):363-6; discussion 366-7. [Medline].

  40. Kobayashi D, Givner LB, Yeatts RP, Anthony EY, Shetty AK. Infantile orbital cellulitis secondary to community-associated methicillin-resistant Staphylococcus aureus. J AAPOS. 2011 Apr. 15 (2):208-10. [Medline].

  41. Seltz LB, Smith J, Durairaj VD, Enzenauer R, Todd J. Microbiology and antibiotic management of orbital cellulitis. Pediatrics. 2011 Mar. 127 (3):e566-72. [Medline].

 
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A male patient with orbital cellulitis with proptosis, ophthalmoplegia, and edema and erythema of the eyelids. The patient also exhibited pain on eye movement, fever, headache, and malaise.
A male patient with orbital cellulitis who demonstrated proptosis, ophthalmoplegia, and edema and erythema of the eyelids. The patient also exhibited chemosis and resistance to retropulsion of the globe.
 
 
 
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