Orbital Cellulitis: The Daily PANCE Blueprint
A 9-year-old girl has had four days of nasal congestion and now presents with a red, swollen right eyelid and a temperature of 38.9°C. She holds the eye closed. When you lift the lid, the globe is proptotic, eye movements are painful and restricted on upgaze, and she reports double vision. Visual acuity is mildly reduced on the right. Which of the following is the most appropriate next step in management?
A. Oral amoxicillin-clavulanate as an outpatient
B. Warm compresses and observation
C. Topical erythromycin ointment
D. IV antibiotics and CT of the orbits
E. Incision and drainage of the eyelid
Answer and topic summary
The answer is D. IV antibiotics and CT of the orbits
Pain with eye movement, restricted motility, proptosis, and reduced vision place this behind the orbital septum — orbital cellulitis, most often spreading from adjacent ethmoid sinusitis. It is an emergency: admit, start IV antibiotics covering Staphylococcus aureus (including MRSA), streptococci, and anaerobes — typically vancomycin plus ceftriaxone or ampicillin-sulbactam — and get a CT of the orbits and sinuses with contrast to look for a subperiosteal or orbital abscess needing drainage. The distinction that carries the whole question is preseptal (periorbital) cellulitis, which is anterior to the septum and causes lid swelling and redness without proptosis, without pain or limitation of eye movement, and without vision change; that one can often be treated with oral antibiotics as an outpatient. Untreated orbital cellulitis threatens vision and can progress to cavernous sinus thrombosis, meningitis, or intracranial abscess.
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