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Orbital cellulitis is characterized by fever, proptosis, restriction of extraocular movements, and swelling with redness of the lids (eFigure 7–71). Immediate treatment with intravenous antibiotics is necessary to prevent optic nerve damage and spread of infection to the cavernous sinuses, meninges, and brain. Infection of the paranasal sinuses is the usual underlying cause. Infecting organisms include S pneumoniae, the incidence of which has been reduced by the administration of pneumococcal vaccine; other streptococci, such as the anginosus group; H influenzae; and, less commonly, S aureus including MRSA. Penicillinase-resistant penicillin, such as nafcillin, is recommended, possibly together with metronidazole or clindamycin to treat anaerobic infections. If trauma is the underlying cause, a cephalosporin, such as cefazolin or ceftriaxone, should be added to ensure coverage for S aureus and group A beta-hemolytic streptococci. If MRSA infection is a concern, vancomycin or clindamycin may be required. For patients with penicillin hypersensitivity, vancomycin, levofloxacin, and metronidazole are recommended. The response to antibiotics is usually excellent, but surgery may be required to drain the paranasal sinuses or orbital abscess. In immunocompromised patients, zygomycosis must be considered.

eFigure 7–71.

Orbital cellulitis. Abscess draining through upper eyelid. (Used, with permission, from M Vagefi.)

WHEN TO REFER

All patients with suspected orbital cellulitis must be referred emergently to an ophthalmologist.

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