Orbital Cellulitis

Orbital (post-septal) cellulitis — usually from ethmoid sinusitis — threatens sight and life. Distinguish from periorbital: proptosis, painful/restricted eye movements, diplopia, reduced acuity/colour vision, RAPD. IV antibiotics + CT + joint…

Post-Septal Infection Pathway

The pathway

1 · Differentiate

Pre-septal: lid signs only, normal vision & movements
Post-septal: proptosis, painful movements, diplopia, visual change, RAPD

2 · Baseline vision

Acuity each eye, colour vision (red desaturation)
Pupils (RAPD), movements
Repeat 4-hourly

3 · IV antibiotics

Blood cultures then IV ceftriaxone 2g OD + metronidazole 500mg TDS (local policy)
Never oral/topical alone

4 · Imaging

Contrast CT orbits + sinuses + brain
Looking for subperiosteal/orbital abscess, intracranial spread

5 · Joint referral

Ophthalmology (vision) + ENT (sinus source) same night
Paediatrics if a child

6 · Surgery if needed

Abscess + visual compromise = emergency drainage
Endoscopic sinus surgery ± orbitotomy

Drugs

Drug	Dose	Route	Notes
Ceftriaxone	2g OD	IV	Broad cover incl. sinus flora. Follow local policy.
Metronidazole	500mg TDS	IV	Anaerobic cover for sinus source.
Flucloxacillin	2g QDS	IV	Added in some local regimens for staphylococcal cover.

When to escalate

Any visual deterioration or new RAPD — emergency drainage discussion,Abscess on CT,Bilateral signs, cranial nerve palsies, meningism — think cavernous sinus thrombosis,Child with orbital cellulitis — senior + paediatrics early

Reference: RCOphth / ENT UK orbital cellulitis guidance; NICE CKS

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