Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets (hemodynamic, neurologic, respiratory) and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Immediate ophthalmology and ENT consultation; obtain contrast imaging.
- Start broad IV antibiotics with MRSA and anaerobic coverage.
- Operate for vision compromise, abscess >10 mm, intracranial extension, or lack of improvement in 24–48 h.
- Monitor vision, EOMs, IOP daily; transition to PO antibiotics when improved.
Clinical Synopsis & Reasoning
Painful ophthalmoplegia, proptosis, and vision changes with fever and sinusitis history suggest orbital cellulitis. Start broad IV antibiotics, obtain contrast CT/MRI of orbits/sinuses, and consult ENT/Ophthalmology for abscess drainage when vision threatened or lack of response to antibiotics.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| Contrast CT orbits/sinuses (or MRI) | Extent/abscess | Subperiosteal/orbital abscess | Plan drainage |
| Ophthalmic exam | Severity | Visual acuity, color vision, RAPD | Baseline and serial |
| Blood cultures/sinus cultures (if OR) | Pathogen ID | Staph/Strep/anaerobes | Guide therapy |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Vancomycin + Ceftriaxone (or cefotaxime) ± Metronidazole | Empiric IV antibiotics | Hours | Cover MRSA, strep, anaerobes | Adjust to culture/local epidemiology |
| Ampicillin‑sulbactam (alternative) | β‑lactam/β‑lactamase inhibitor | Hours | Monotherapy option | Add MRSA coverage if needed |
| Topical lubrication/IOP management (adjunct) | Supportive | Immediate | Prevent exposure/corneal injury | — |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- AAO/ENT joint recommendations and reviews on orbital cellulitis — Link