A 7-year-old girl is brought to the emergency department for evaluation of right eye swelling and redness that began 24 hours ago. She had a mild upper respiratory infection last week. Past medical history is otherwise negative. Her temperature is 38.2°C (100.8°F), pulse is 105/min, and respiratory rate is 20/min. Physical examination shows erythema and significant edema of the right upper and lower eyelids. The child is able to open the eye spontaneously. Visual acuity is 20/20 in both eyes. Extraocular movements are intact and painless. There is no proptosis, chemosis, or resistance to retropulsion. The remainder of the physical examination is unremarkable.
Which of the following is the most appropriate next step in management?
The correct answer is:
A) Amoxicillin-clavulanate
This patient presents with preseptal cellulitis, an infection of the soft tissues anterior to the orbital septum. It is most commonly a complication of local skin trauma such as an insect bite or spread from an upper respiratory infection or sinusitis. In this case, the absence of red flag findings such as proptosis, ophthalmoplegia (pain with or limitation of extraocular movements), or decreased visual acuity confirms the diagnosis of preseptal cellulitis rather than the more severe orbital cellulitis. For children over the age of one year who are clinically stable, have mild symptoms, and no evidence of systemic toxicity, management consists of outpatient oral antibiotics. Amoxicillin-clavulanate provides appropriate coverage for common pathogens, including Streptococcus pneumoniae, other streptococci, and Staphylococcus aureus.
Answer choice B: Computed tomography of the orbits, is incorrect. Imaging is indicated if there is suspicion of orbital cellulitis, such as proptosis, restricted eye movements, or if the physical exam is limited by severe swelling. In a straightforward case of preseptal cellulitis with a normal ocular exam, imaging is not necessary.
Answer choice C: Hospitalization and intravenous vancomycin, is incorrect. This is part of the management for orbital cellulitis or for patients with preseptal cellulitis who are under age one, appear toxic, or fail to improve on outpatient therapy. This patient is stable and has no features of post-septal involvement.
Answer choice D: Incision and drainage, is incorrect. This procedure is reserved for patients who have developed a fluctuant abscess. There is no mention of a localized abscess on this patient's physical examination.
Answer choice E: Ophthalmology consultation, is incorrect. While an ophthalmologist should be consulted if orbital cellulitis or an abscess is suspected, uncomplicated preseptal cellulitis can be managed by a primary care physician or emergency medicine physician.
Key Learning Point
The clinical differentiation between preseptal and orbital cellulitis is critical: preseptal cellulitis involves only the eyelid and superficial tissues and lacks proptosis, pain with extraocular movement, or vision loss. Management for mild preseptal cellulitis is typically outpatient oral antibiotics (e.g., amoxicillin-clavulanate), whereas orbital cellulitis requires hospitalization, intravenous antibiotics, and often imaging to rule out an orbital abscess.
