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Orbital Infections Treatment & Management

  • Author: Keith A Lafferty, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
Updated: Jul 02, 2014

Emergency Department Care

Patients with preseptal cellulitis may be discharged home with oral antibiotics and close follow up 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).

Initiation of intravenous antibiotics should not be delayed for imaging if the clinical suspicion is high. Appropriate selections include cefuroxime or ampicillin-sulbactam. Clindamycin or metronidazole can be added if cefuroxime is used and anaerobic infection is likely. Considering the emergence of community-acquired MRSA and penicillin-resistant S pneumoniae, vancomycin may be added. Also, if a patient presents with life- or vision-threatening disease, vancomycin may be added to ampicillin/sulbactam.

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.[20]

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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Contributor Information and Disclosures

Keith A Lafferty, MD Adjunct Assistant Professor of Emergency Medicine, Temple University School of Medicine; Medical Student Director, Department of Emergency Medicine, Gulf Coast Medical Center

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

Disclosure: Nothing to disclose.


Keisha Bonhomme, MD Resident Physician, Department of Internal Medicine, St Vincent’s Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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 Professor, 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 Oncology Association of Practices, Southern Clinical Neurological Society, Wilderness Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Palmetto Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Columbia Medical Society, Society for Academic Emergency Medicine, South Carolina College of Emergency Physicians, South Carolina Medical Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Employed contractor - Chief Editor for Medscape.

Additional Contributors

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, American Medical Informatics Association, Medical Association of Georgia

Disclosure: Nothing to disclose.


Robert G Hendrickson, MD Associate Professor of Emergency Medicine, Oregon Health and Science University School of Medicine; Attending Physician, Medical Director, Emergency Management Program, Department of Emergency Medicine, Oregon Health and Science University Hospital and Health Systems; Associate Medical Director, Director, Fellowship in Medical Toxicology, Disaster Preparedness Coordinator, Oregon Poison Center; Clinical Toxicologist, Alaska Poison Center and Guam Poison Center

Robert G Hendrickson, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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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.
Lamina papyracea.
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