Eye pain and discharge

Question 1

Inflammation of the bulbar and or palpebral
conjunctiva

Answer 1

Conjunctivitis

Question 2

What is the pathophysiology of conjunctivitis?

Answer 2

Patho
- Alterations in the host defense, external contamination
(contact lens, swimming) –> bacterial/ viral infection

Question 3

Etiology of Bacterial conjunctivitis

Answer 3

Etiology
- Nontypeable Haemophilus influenzae (60-80%),
Haemophylus aegyptius, S.pneumoniae, S.aureus,
M.catarrhalis
- Common <5yo

Question 4

What are the clinical manifestations of conjucntivitis?

Answer 4

CM
1. Mucopurulent unilateral or bilateral discharge,
hyperemia, edema
2. Glued eyes (lids stuck after sleeping)
3. N vision
4. Photophobia, ocular pain and discomfort

Question 5

What is the management of conjunctivitis?

Answer 5

Mgt
1. topical abx – Moxifloxacin (Vigamox) 0.5% ophthalmic
solution 1 qtts tidx7d
tobramycin (Tobrex) 0.3% eye drops, 1-2 qtts q4h
2. IV ceftriaxone 50-75 mkd IV q12 for gonococcus, HiB
3. Warm compress

Question 6

What is the epidemiology of viral conjunctivitis?

Answer 6

Etiology
- Adenovirus, ECHO virus, coxsackievirus, HSV
- More common adults, >5yo

Question 7

Clinical manifestations of viral conjunctivitis

Answer 7

CM
1. Conjunctival injection and chemosis
2. Gritty sensation
3. Watery discharge
4. Often unilateral
5. (+) periauricular LNE

Question 8

Management of viral conjunctivitis

Answer 8

self-limited

Question 9

Etiology of allergic conjunctivitis

Answer 9

• Seasonal pollens or allergen exposure

Question 10

Clinical manifestations of allergic conjunctivitis

Answer 10

CM
1. Itching
2. Bilateral edema (chemosis) > erythema
3. Tarsal papillae
4. Clear watery discharge

Question 11

Management of allergic conjunctivitis

Answer 11

Mgt
1. Cold compress
2. Antihistamines: Azelastine 0.05% solution, 1 drop each
eye q6-12h, Olapatadine 0.2% eye drops, 1 drop each
eye OD
3. Topical mast cell stabilizers or prostaglandin inhibitors
4. NSAID eye drops – Ketorolac eye drops
5. Steroids – fluocinolone, loteprednol eye drops

Question 12

What is orbital cellulitis?

Answer 12

• Inflammation of tissues of the orbit
• Infection posterior to the orbital septum
• Usually 10mo-18 yo (mean 7yo)

Etiology
- S.aureus, MRSA, Haemophilus

Question 13

Pathophysiology of orbital cellulitis

Answer 13

Patho
- Follow a direct infection of the orbit from a wound,
metastatic deposition of org during bacteremia, or
direct extension or venous spread of infection from
contiguous sites (lids, conjunctiva, globe, lacrimal
gland, nasolacrimal gland, ethmoid sinus)
- Paranasal sinusitis: most common cause in children
- More prevalent in children because:
o Thinner bony septa and sinus wall
o Greater porosity of bones
o Open suture lines
o Larger vascular foramina

Question 14

What are the clinical manifestations of orbital cellulitis?

Answer 14

1. proptosis, limitation of eye movt, ophthalmoplegia,
   ocular pain
2. chemosis, inflammation and swelling of the eyelid,
   warm, tender, erythematous lid swelling mucoid
   discharge, conjunctival swelling
3. decreased VA

Question 15

What are the complications of orbital cellulitis?

Answer 15

Complication
1. visual loss due to retinal artery occlusion or optic
neuritis
2. cavernous sinus thrombosis
3. meningitis
4. epidural or subdural empyema

Question 16

Diagnostics for orbital cellulitis?

Answer 16

Dx
1. contrast CT of orbit – to r/o subperiosteal abscess,
orbital abscess, intracranial extension. Orbital fat
stranding, globe tenting is an adverse prognostic sign
2. CBC, BCS, eye discharge GS/CS – leukocytosis with left
shift

Question 17

Management of orbital cellulitis

Answer 17

Mgt
1. Vancomycin 45-60 mkd IV q6/8
2. Cefotaxime 100-200 mkd q6/8 IV
3. Ceftriaxone 50-75 mkd IV q12/24
4. I&D – if with abscess
5. Refer to ophtha

Question 18

What is preseptal cellulitis and give the etiology?

Answer 18

• Infection of soft tissues anterior to the orbital septum
• Form of facial cellulitis

Etiology:
- GAS, S.aureus, pneumococcus

Question 19

What is the pathophysiology of preseptal cellulitis?

Answer 19

Patho
- Caused by sinusitis, trauma, infected wound,
bacteremia, abscess of lid or periorbital region
(pyoderma, hordeolum, conjunctivitis, insect bite) à
Inflammation of the lids and periorbital tissues without
signs of true orbital involvement

Question 20

What are the clinical manifestations of preseptal cellulitis?

Answer 20

CM
1. Eyelid swelling
2. No proptosis or LOM of eye, N pupil function
3. Warm, tender, erythematous lid swelling, mucoid
discharge, conjunctival swelling

Question 21

Diagnostics for preseptal cellulitis

Answer 21

Dx
Clinical
1. CT scan – consider for children with advanced infection
or suspicion of FB. edema of lids and adjacent
preseptal soft tissues, SC tissues, obliteration of fat
planes or details of the preseptal soft tissues, absence
of orbital inflammation
2. CBC, BCS, eye discharge GS/CS – leukocytosis with left
shift

Question 22

Management of preseptal cellulitis

Answer 22

Mgt
1. Abx – Cotrimoxazole 8-12 mkd IV/po q12 /clindamycin
30 mkd q6/8 IV/po + Amoxicillin 25-50 mkd po q8/12
/Coamoxiclav 20-40 mkd po q8/12
2. WOF sx progression to orbital cellulitis