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.
See the list below:
Infectious disease specialists
Mathew A, Craig E, Al-Mahmoud R, Batty R, Raghavan A, Mordekar S, et al. Paediatric Post-septal and Pre-septal Cellulitis: 10-year Experience at a Tertiary-level Children's Hospital. Br J Radiol. 2013 Nov 28. [Medline].
Hightower S, Chin EJ, Heiner JD. Detection of increased intracranial pressure by ultrasound. J Spec Oper Med. 2012. 12(3):19-22. [Medline].
Wayman D, Carmody KA. Optic Neuritis Diagnosed by Bedside Emergency Physician-Performed Ultrasound: A Case Report. J Emerg Med. 2014 Mar 15. [Medline].
Ahmad R, Salman R, Islam S, Rehman A. Cavernous Sinus Thrombosis As A Complication Of Sphenoid Sinusitis: A Case Report And Review Of Literature. Internet J Otorhinolaryngol. 12(1):[Full Text].
Ben Abdallah Chabchoub R, Kmiha S, Turki F, Trabelsi L, Maalej B, Ben Salah M, et al. [Septic cavernous sinus thrombosis following ethmoiditis: A case report.]. Arch Pediatr. 2013 Nov 26. [Medline].
Bhatia K, Jones NS. Septic cavernous sinus thrombosis secondary to sinusitis: are anticoagulants indicated? A review of the literature. J Laryngol Otol. 2002 Sep. 116(9):667-76. [Medline].
Stam J. Thrombosis of the cerebral veins and sinuses. N Engl J Med. 2005 Apr 28. 352(17):1791-8. [Medline].
Botting AM, McIntosh D, Mahadevan M. Paediatric pre- and post-septal peri-orbital infections are different diseases. A retrospective review of 262 cases. Int J Pediatr Otorhinolaryngol. 2008 Mar. 72(3):377-83. [Medline].
Ambati BK, Ambati J, Azar N. Periorbital and orbital cellulitis before and after the advent of Haemophilus influenzae type B vaccination. Ophthalmology. 2000 Aug. 107(8):1450-3. [Medline].
DeMuri GP, Wald ER. Clinical practice. Acute bacterial sinusitis in children. N Engl J Med. 2012 Sep 20. 367(12):1128-34. [Medline].
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].
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. 2007 Aug. 144(2):313-5. [Medline].
McKinley SH, Yen MT, Miller AM, Yen KG. Microbiology of pediatric orbital cellulitis. Am J Ophthalmol. 2007 Oct. 144(4):497-501. [Medline].
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].
Mills DM, Tsai S, Meyer DR, Belden C. Pediatric ophthalmic computed tomographic scanning and associated cancer risk. Am J Ophthalmol. 2006 Dec. 142(6):1046-53. [Medline].
Younis RT, Anand VK, Davidson B. The role of computed tomography and magnetic resonance imaging in patients with sinusitis with complications. Laryngoscope. 2002 Feb. 112(2):224-9. [Medline].
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].
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. 2009 Sep. 193(3):W244-50. [Medline].
Hennemann S, Crawford P, Nguyen L, Smith PC. Clinical inquiries. What is the best initial treatment for orbital cellulitis in children?. J Fam Pract. 2007 Aug. 56(8):662-4. [Medline].
Donahue SP, Schwartz G. Preseptal and orbital cellulitis in childhood. A changing microbiologic spectrum. Ophthalmology. 1998 Oct. 105(10):1902-5; discussion 1905-6. [Medline].
Farnath D. Ocular infections. Infectious Disease in Emergency Medicine. 2nd ed. 1998. 843-58.
Ghezzi K, Renner GS. Ophthalmologic disorders. Emergency Medicine. Concepts and Clinical Practice. 1992. 2427-59.
Gordon LK. Diagnostic dilemmas in orbital inflammatory disease. Ocul Immunol Inflamm. 2003 Mar. 11(1):3-15. [Medline].
Hendrickson RG, Olshaker J, Duckett O. Rhinocerebral mucormycosis: a case of a rare, but deadly disease. J Emerg Med. 1999 Jul-Aug. 17(4):641-5. [Medline].
Kraus DJ, Bullock JD. Orbital infections. Pepose JS, Holland G, Wilheimus K, eds. Ocular Infection and Immunity. Mosby-Year Book; 1996. 1321-40.
Mahalingam-Dhingra A, Lander L, Preciado DA, Taylormoore J, Shah RK. Orbital and periorbital infections: a national perspective. Arch Otolaryngol Head Neck Surg. 2011 Aug. 137(8):769-73. [Medline].
Prentiss KA, Dorfman DH. Pediatric ophthalmology in the emergency department. Emerg Med Clin North Am. 2008 Feb. 26(1):181-98, vii. [Medline].
Rumelt S, Rubin PA. Potential sources for orbital cellulitis. Int Ophthalmol Clin. 1996 Summer. 36(3):207-21. [Medline].
Wald ER. Periorbital and orbital infections. Infect Dis Clin North Am. 2007 Jun. 21(2):393-408, vi. [Medline].
Westfall CT, Shore JW, Baker AS. Orbital infections. Infectious Diseases. 2nd ed. 1373-7.
Yohai RA, Bullock JD, Aziz AA, Markert RJ. Survival factors in rhino-orbital-cerebral mucormycosis. Surv Ophthalmol. 1994 Jul-Aug. 39(1):3-22. [Medline].