Preseptal and Orbital Cellulitis Management

Clinical Assessment and Immediate Management

Urgent ophthalmologic examination is required to distinguish preseptal cellulitis from orbital cellulitis, as the American Academy of Ophthalmology emphasizes that symptoms of pain and visual disturbance require immediate specialist assessment to prevent severe visual morbidity 1
Visual acuity testing, pupil examination, extraocular motility assessment, and intraocular pressure measurement must be performed immediately, as these baseline measurements help differentiate preseptal from orbital involvement 1
Red streaking (lymphangitis) indicates active bacterial spread and represents a medical urgency requiring same-day treatment initiation 1
Proptosis, ophthalmoplegia, or decreased vision would indicate orbital involvement requiring IV antibiotics and possible surgical intervention 1
Pain with eye movement or relative afferent pupillary defect suggests posterior extension beyond the orbital septum 1
Elevated intraocular pressure could indicate angle-closure crisis rather than or in addition to infection, requiring immediate pressure-lowering therapy 1

Oral antibiotics covering Staphylococcus aureus and Streptococcus species are first-line for preseptal cellulitis without orbital involvement 2
Emergent CT imaging of orbits and sinuses to assess for abscess formation requiring surgical drainage is necessary for orbital cellulitis 3
Continue current glaucoma medications unless contraindicated by systemic antibiotic therapy, and monitor intraocular pressure closely during the infection 2
Avoid systemic corticosteroids if possible, as they can elevate intraocular pressure in glaucoma patients 2
Postpone any scheduled anti-VEGF injections until the periocular infection has completely resolved to avoid introducing infection into the eye 3

Re-examine within 24-48 hours to ensure clinical improvement on antibiotics 3
Immediate return if worsening (increased pain, vision changes, proptosis, fever) suggesting progression to orbital cellulitis 1
Resume routine glaucoma and AMD monitoring once infection resolves, as patients with glaucoma require regular IOP monitoring and visual field testing, and AMD patients need ongoing assessment for disease progression 2, 3