Orbital Cellulitis (Postseptal) — Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Preseptal vs postseptal
   Preseptal vs postseptal? (pain on eye movement/proptosis/ophthalmoplegia) (Infection of postseptal soft tissue (muscle/fat) (vs preseptal = eyelid only); more common in children, 86–98% from sinusitis (ethmoid), also odontogenic/traumatic. Key distinguishing features: pain on eye movement + proptosis + ophthalmoplegia + chemosis ± reduced vision/RAPD + fever and raised WBC (eyelid swelling occurs in both and does not differentiate); bilateral → suspect cavernous sinus thrombosis. Complications: vision loss (~11%)/subperiosteal or orbital abscess/cavernous sinus thrombosis/meningitis/brain abscess.)
   • Postseptal (pain on movement/proptosis/ophthalmoplegia/reduced vision) → Postseptal → admit + IV antibiotics
   • Preseptal (eyelid swelling only, none of the above) → Preseptal · oral antibiotics + follow-up
2. [End] Preseptal · oral antibiotics + follow-up
   Preseptal cellulitis (eyelid swelling only, no pain on movement/proptosis/ophthalmoplegia, normal vision): oral antibiotics (cover Staph/Strep) + close follow-up; any pain on eye movement/proptosis/ophthalmoplegia/reduced vision → contrast CT and manage as postseptal (normal vision does not exclude orbital cellulitis).
3. [End] Postseptal → admit + IV antibiotics
   Postseptal (orbital cellulitis): admit + contrast CT of orbits + sinuses (look for subperiosteal/orbital abscess and source) + IV broad-spectrum antibiotics (cover MRSA + Strep + anaerobes, e.g. vancomycin + ceftriaxone/ampicillin-sulbactam ± metronidazole) + ophthalmology/ENT consult; nasal decongestants/irrigation; surgical drainage — orbital abscess/large or non-resolving subperiosteal abscess/visual deterioration/no improvement on antibiotics at 24–48 h/intracranial complications; orbital compartment syndrome (acute visual threat, raised IOP, proptosis) → emergency lateral canthotomy.

Source guidelines & references

• Orbital cellulitis (StatPearls; Merck Manual; EyeWiki)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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