Orbital Infections Treatment & Management

  • Author: Keith A Lafferty, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Oct 31, 2011
 

Emergency Department Care

Adults with preseptal cellulitis and no signs of orbital involvement can be discharged on oral antibiotics with close follow-up care. Patients with preseptal cellulitis may be discharged home with oral antibiotics only after ruling out postseptal disease either clinically or radiographically. Admit patients with orbital signs and quickly initiate IV antibiotics or antifungals and, if necessary, surgical intervention.

For orbital cellulitis, empiric antimicrobial therapy should be chosen to provide activity against S aureus, S pyogenes, and anaerobic bacteria of the upper respiratory tract in addition to the usual pathogens associated with acute sinusitis (ie, S pneumoniae, H influenzae, and M catarrhalis). Appropriate selections include cefuroxime or ampicillin-sulbactam. Clindamycin or metronidazole can be added if cefuroxime is used and anaerobic infection is likely. If a patient presents with life- or vision-threatening disease, vancomycin may be added to ampicillin/sulbactam for coverage of community-acquired MRSA or penicillin-resistant S pneumoniae. Appropriate coverage in children includes nafcillin plus ceftriaxone and metronidazole for orbital cellulitis. For pediatric patients allergic to penicillin, vancomycin plus levofloxacin and metronidazole are recommended.[12]

Intravenous therapy is maintained until the infected eye appears nearly normal. At that time, oral antibiotic therapy can be substituted to complete a 3-week course of treatment

Nasal decongestants can be used to help drain the sinuses.

All diabetic patients with possible orbital cellulitis should have fungal infection excluded via NPL because rhinocerebral mucormycosis frequently manifests as orbital cellulitis.

Surgical drainage generally is not necessary for cellulitis; however, any patient with compromised vision (20/60 or worse), well-defined abscess, or complete ophthalmoplegia should receive immediate surgery for drainage and debridement. Consider surgical drainage of abscesses (orbital or subperiosteal) without visual loss. Consider drainage of sinuses as well. Some patients can be monitored for 48 hours on IV antibiotics, with surgery performed for increasing proptosis, worsening visual acuity, or isolated muscle weakness. Surgery is performed after 48 hours fever continues or antibiotics fail. Several studies have shown successful drainage of a subperiosteal abscess by endoscopy, which avoids an external incision.

In the case of CST, anticoagulation therapy seems warranted. However, there are no controlled perspective studies showing any benefit. In patients with noninfectious dural sinus thrombosis, about 40% have hemorrhagic infarcts even before anticoagulation has been started, although no increase in intracranial hemorrhages was demonstrated after the initiation of heparin products.

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Consultations

  • Ophthalmologists
  • Infectious disease specialists
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Contributor Information and Disclosures
Author

Keith A Lafferty, MD  Adjunct Assistant Professor of Emergency Medicine, Temple University; Consulting Staff, Department of Emergency Medicine, South West Regional Medical Center

Keith A Lafferty, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association, and Pennsylvania Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Keisha Bonhomme  Ross University School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Eric M Kardon, MD, FACEP  Attending Emergency Physician, Georgia Emergency Medicine Specialists; Physician, Division of Emergency Medicine, Athens Regional Medical Center

Eric M Kardon, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians

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

Eric L Weiss, MD, DTM&H  Medical Director, Office of Service Continuity and Disaster Planning, Fellowship Director, Stanford University Medical Center Disaster Medicine Fellowship, Chairman, SUMC and LPCH Bioterrorism and Emergency Preparedness Task Force, Clinical Associate Progressor, Department of Surgery (Emergency Medicine), Stanford University Medical Center

Eric L Weiss, MD, DTM&H is a member of the following medical societies: American College of Emergency Physicians, American College of Occupational and Environmental Medicine, American Medical Association, American Society of Tropical Medicine and Hygiene, Physicians for Social Responsibility, Southeastern Surgical Congress, Southern Association for Oncology, Southern Clinical Neurological Society, and Wilderness Medical Society

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Robert G Hendrickson, MD, to the development and writing of this article.

References

  1. Bhatia K, Jones NS. Septic cavernous sinus thrombosis secondary to sinusitis: are anticoagulants indicated? A review of the literature. J Laryngol Otol. Sep 2002;116(9):667-76. [Medline].

  2. Stam J. Thrombosis of the cerebral veins and sinuses. N Engl J Med. Apr 28 2005;352(17):1791-8. [Medline].

  3. Ambati BK, Ambati J, Azar N. Periorbital and orbital cellulitis before and after the advent of Haemophilus influenzae type B vaccination. Ophthalmology. Aug 2000;107(8):1450-3. [Medline].

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

  5. Freidlin J, Acharya N, Lietman TM, Cevallos V, Whitcher JP, Margolis TP. Spectrum of eye disease caused by methicillin-resistant Staphylococcus aureus. Am J Ophthalmol. Aug 2007;144(2):313-5. [Medline].

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

  7. 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]. [Full Text].

  8. Mills DM, Tsai S, Meyer DR, Belden C. Pediatric ophthalmic computed tomographic scanning and associated cancer risk. Am J Ophthalmol. Dec 2006;142(6):1046-53. [Medline].

  9. Younis RT, Anand VK, Davidson B. The role of computed tomography and magnetic resonance imaging in patients with sinusitis with complications. Laryngoscope. Feb 2002;112(2):224-9. [Medline].

  10. Parmar H, Gandhi D, Mukherji, SK, Trobe JD. Restricted Diffusion in the Superior Ophthalmic Vein and Cavernous Sinus in a Case of Cavernous Sinus Thrombosis. J Neuro-Ophthalmol. 2009;29;1:16-20. [Medline].

  11. Sepahdari AR, Aakalu VK, Kapur R, Michals EA, Saran N, French A, et al. MRI of orbital cellulitis and orbital abscess: the role of diffusion-weighted imaging. AJR Am J Roentgenol. Sep 2009;193(3):W244-50. [Medline].

  12. Hennemann S, Crawford P, Nguyen L, Smith PC. Clinical inquiries. What is the best initial treatment for orbital cellulitis in children?. J Fam Pract. Aug 2007;56(8):662-4. [Medline].

  13. Donahue SP, Schwartz G. Preseptal and orbital cellulitis in childhood. A changing microbiologic spectrum. Ophthalmology. Oct 1998;105(10):1902-5; discussion 1905-6. [Medline].

  14. Farnath D. Ocular infections. In: Infectious Disease in Emergency Medicine. 2nd ed. 1998:843-58.

  15. Ghezzi K, Renner GS. Ophthalmologic disorders. In: Emergency Medicine. Concepts and Clinical Practice. 1992:2427-59.

  16. Gordon LK. Diagnostic dilemmas in orbital inflammatory disease. Ocul Immunol Inflamm. Mar 2003;11(1):3-15. [Medline].

  17. Hendrickson RG, Olshaker J, Duckett O. Rhinocerebral mucormycosis: a case of a rare, but deadly disease. J Emerg Med. Jul-Aug 1999;17(4):641-5. [Medline].

  18. Kraus DJ, Bullock JD. Orbital infections. In: Pepose JS, Holland G, Wilheimus K, eds. Ocular Infection and Immunity. Mosby-Year Book; 1996:1321-40.

  19. Prentiss KA, Dorfman DH. Pediatric ophthalmology in the emergency department. Emerg Med Clin North Am. Feb 2008;26(1):181-98, vii. [Medline].

  20. Rumelt S, Rubin PA. Potential sources for orbital cellulitis. Int Ophthalmol Clin. Summer 1996;36(3):207-21. [Medline].

  21. Wald ER. Periorbital and orbital infections. Infect Dis Clin North Am. Jun 2007;21(2):393-408, vi. [Medline].

  22. Westfall CT, Shore JW, Baker AS. Orbital infections. In: Infectious Diseases. 2nd ed. 1373-7.

  23. Yohai RA, Bullock JD, Aziz AA, Markert RJ. Survival factors in rhino-orbital-cerebral mucormycosis. Surv Ophthalmol. Jul-Aug 1994;39(1):3-22. [Medline].

 
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Complications of orbital infections. Brain abscess in a young man secondary to an orbital infection from Mucor species.
Orbital infections. Orbital abscess with significant proptosis.
Orbital infections. Subperiosteal abscess with contiguous sinusitis.
Orbital infections. Subperiosteal abscess with contiguous sinusitis.
Orbital infections. Frontal sinusitis.
Orbital infections. Orbital abscess with significant proptosis.
Cavernous sinus and its cranial nerves.
Orbital cellulitis; chemosis.
 
 
 
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