Orbital Infections Treatment & Management
- Author: Keith A Lafferty, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD more...
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.
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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Infectious disease specialists
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