Download 4.Orb cell

Diseases of the orbit
Orbital Cellulitis
Dr. Ayesha S Abdullah
19.08.2016
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Learning objectives
By the end of the lecture the students should be
able to
1. Differentiate between preseptal and true orbital
cellulitis
2. Explain why it is considered to be an ocular
emergency
3. Describe the causes,
4. Explain the clinical presentation, complications
& line of management of orbital cellulitis
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Orbital cellulitis
• Preseptal cellulitis
• True orbital cellulitis
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Preseptal orbital cellulitis
• Infection of the subcutaneouss tissue
anterior to the orbital septum ( lids)
• Causes:
– Trauma; lid laceration/ insect bite
– Spread from local infection; stye/
dacrocystitis, dental infection
– Spread from remote infection;
haemotogenous spread from middle ear/
Upper Respiratory Tract
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Preseptal orbital cellulitis
• Clinical presentation
– Symptoms; History of predisposing factor,
pain & swelling of the lid, mild fever
– Signs; red swollen tender lids sometimes the
lids may be difficult to open. Important
negative signs are:
• Eye itself is normal at the most might be mildly
congested
• Visual acuity is normal
• No proptosis
• No ocular motility problem
• Normal pupils
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Preseptal orbital cellulitis
• Complications
– True orbital cellulitis
– Lid abscess
– Cavernous sinus thrombosis
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Management of Preseptal orbital cellulitis
• Symptomatic; analgesics & NSAIDS
• Specific:
• Very severe infections may require Adults:
250 – 500 mg oral Co-amoxiclav qds/ tds
depending on severity of infection.
• Children: 20-40mg/kg/day oral co-amoxiclav
over 24h in three divided doses.
• benzylpenicillin 2.4-4.8 mg I/M 6 hourly in
severe infections
• Lid abscesses should be drained
• Third generation cephalosporins in penicillin
allergy
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Orbital cellulitis
• Infection of the soft tissues behind the
orbital septum ( deeper to lids)
• Ocular emergency , could be life
threatening
• Most frequent pathogens are;
– Strept. Pneumoniae ,
– Staph aureus,
– Strept. Pyogenes & H influenzae - (under 5yr)
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Causes
• Spread from the sinuses; mostly
ethmoidal in children & young adults
• Extension from preseptal cellulitis
• Local spread; dacrocystitis, dental
infection, facial infection, infection of
the eyeball ( panophthalmitis etc)
• Haemotogenous spread
• Post- traumatic; accidental/ surgical
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Clinical presentation
• Symptoms; rapid onset painful swelling
of the lids & protrusion of the eye,
fever, malaise & visual loss ; history of
risk factors
• Signs; moderate to severe swelling of
the lids, reduced visual acuity,
proptosis,red eye with chemosis of the
conjunctiva, abnormal & painful EOM &
pupillary response
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Management
• Admit
• Symptomatic; antipyretic, NSAIDS
• Specific ; hospitalization & antibiotic therapy
– Ceftazidime/ Cftriaxone/ Cefuroxime 1 g tds , I/V
– Mteronidazole 500mg tds, PO / IV
– Vancomycin in case of allergy to the above mentioned
• Surgical intervention in case of local abscess or
unresponsive cases
• Consultation with ENT specialist, neurosurgeon &
paediatrician if required
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Complications
Ocular; corneal damage( exposure),raised
IOP, vascular occlusions, optic nerve
damage, endophthalmitis
Intracranial; meningitis, brain abscess,
cavernous sinus thrombosis
Orbital abscess
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Case #1
A 1 year old child presented to the OPD of
department of ophthalmology with the
complaint of a swollen right upper lid for the
last two days. On examination the lid was
red, warm & tender to touch. His visual acuity
was normal, the eye had mild conjunctival
redness, the pupil was normal and the ocular
movements were also normal. Watch the
photograph….
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Some questions
1. Is the condition confined to the lids or has it
involved the eyeball?
2. Why do you think so?
3. What more information would you like to
have before making a diagnosis?
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Some more information………
• The child had a history of insect bite on
the lid two days ago, the swelling
increased thereafter. The insect bite
mark was visible
• There was no history of trauma or
symptoms suggestive of sinusitis
• His temperature was 99.80 F
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Some more questions
• What should be the management,
keeping in mind the nature of the
problem?
• Is there any role of health education in
this case?
Let us see an other case……..
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Case #2
• A seven year old child was brought the OPD of the
department of ophthalmology with a history of
swollen left upper lid for the last 5 days. He also had
fever for the last two days. On examination the child
had a grossly swollen lid. The doctor had difficulty in
opening the lid for examination of the eye. The visual
acuity was 6/6 OD & 6/18 OS. The lid was warm and
tender. The eye was moderately proptosed with
conjunctival chemosis. The pupil was slow to react to
light and the ocular movements were painful &
limited. The temperature was 1010 F & the child
looked generally unwell……..
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Some questions….
1. Is the condition confined to the lids or has it
involved inner orbit?
2. What more information should we ask for to
get an idea about the cause of the problem?
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• The child had a history of recurrent flu
and upper respiratory tract infections.
He had history of blocked nose and
thick greenish nasal discharge was
noted on examination.
• The child was put on intravenous
antibiotics but didn’t get better
• Why?
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The antibiotics were changed to intravenous
ampicillin/sulbactam and after 5 days were changed to
oral amoxicillin/clavulanic acid for a total of 14 days of
antibiotics.
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Some more questions
• What should be the management,
keeping in mind the nature of the
problem?
• What do you think can be done with the
abscess?
• Is there any role of health education in
this case?
..
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Conclusion about the two cases
• What is the difference between the two
cases?
• We consider the second case an ocular
emergency, why?
• Why did the subperiosteal abscess form
in the second case?
• What other complications could happen
in the second case?
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Let us summarize
• Preseptal orbital cellulitis & orbital
cellulitis are both infections.
• It is more common in children
• The route of infection could be from the
nearby infectious focus like infected
sinuses, skin wound or spread of
infection via blood
• The most common cause especially in
children is ethmoidal sinusitis
•
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• Both preseptal and orbital cellulitis may
have:
– Fever
– Eyelid swelling
– Pain
– Red eye
– Child is ill-appearing
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• Orbital cellulitis signifies spread of
inflammation to the posterior orbital
contents that is the eyeball, extraocular
muscles: helpful signs to distinguish it
are:– Proptosis
– Decreased visual acuity ( may be normal in
the beginning)
– Red eye with conjunctival chemosis of
moderate to intense congestion
– Painful limited eye movements
– Afferent pupillary defect
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• Prior to the availability of antibiotics, patients
with orbital cellulitis had a mortality rate of
17%, and 20% of survivors were blind in the
affected eye. However, with prompt diagnosis
and appropriate use of antibiotics, this rate
has been reduced significantly
• blindness can still occur in up to 11% of
cases. Orbital cellulitis due to methicillinresistant Staphylococcus aureus can lead to
blindness despite antibiotic treatment.
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Preseptal Cell.
Orbital Cell.
Vision
Normal
Reduced
Lid swelling
Present
Present
Proptosis
Absent
Present
Colour vision
Normal
May be reduced *
Ocular movements Normal
Painful/
restricted*
RAPD
May be present*
Absent
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