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Disease 1 > Lecture 2 - Orbital Infection to Wegeners > Flashcards

Lecture 2 - Orbital Infection to Wegeners Flashcards

1
Q

Fascia behind the orbicularis, between the orbital rim and tarsus, serves as a BARRIER BETWEEN LIDS AND ORBIT

A

Orbital Septum

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2
Q

superior orbital septum blends with the tendon of which lid muscle

A

Levator palpabrae

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3
Q

inferior orbital septum blends with which lid muscle?

A

inferior tarsus

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4
Q

Chandler classification for infections of the orbit and adnexa: What is stage 1?

A

NORMAL septum - preseptal cellulitis

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5
Q

Chandler classification for infections of the orbit and adnexa: What is stage 2?

A

Diffuse cellulitis - contained in cone and EOMs

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6
Q

Chandler classification for infections of the orbit and adnexa: what is stage 3?

A

Subperiosteal abscess - abscess outside of the muscle cone

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7
Q

Chandler classification for infections of the orbit and adnexa: what is stage 4?

A

Abscess contained within the orbit

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8
Q

Chandler classification for infections of the orbit and adnexa: what is stage 5?

A

Cavernous sinus thrombosis

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9
Q

Infection of the soft tissue of eye lids anterior to the orbital septum - no involvement of globe and orbit - injury, bites, conjunctivitis, sinusitis, chalazion - Usually Staph Aureus or Strep

A

Preseptal Cellulitis

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10
Q

What 2 anaerobic bacteria should be suspected in cases involving preseptal cellulitis caused by human or ANIMAL bites?

A

peptostreptococcus and bacteroides

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11
Q

which bacteria should be suspected in preseptal cellulitis cases caused by skin trauma: laceration or INSECT bites

A

S. Aureus, S. Pyogenes

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12
Q

From where in the body can bacteria travel hematogenously to cause a remote infection in the form of preseptal cellulits? (2)

A

upper respiratory tract or middle ear

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13
Q

Is Preseptal cellulitis unilateral? is there proptosis or EOM restriction? can the eye always open? are VA’s affected? What are the symptoms you would expect? what will a CT show?

A

unilateral, no proptosis/restriction, cant always open eye, No VA effect, fever, redness/ tenderness/ irritable children - Opacification anterior to septum

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14
Q

What is unique about preseptal cellulitis cases that are caused by H. Influenza?

A

Red-Purplish in color, important to ask about vaccines

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15
Q

You suspect preseptal cellulitis, but upon further testing, you observe proptosis, pain with EOM test, decreased VA, fever, and chemosis. What is the differential diagnosis?

A

ORBITAL cellulitis

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16
Q

You suspect preseptal cellulitis, but then observe acute inflammation (not entire lid area), a palpable mass, and pointy meibomian gland. What is the diferential diagnosis?

A

Chalazion

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17
Q

You suspect preseptal cellulitis, but upon further testing you find there was sudden onset, itching, redness, a history of allergies, and the patient began using a new kind of eye product (cls solution, drops etc) . What is the differential diagnosis?

A

Swelling of the eyelid due to an allergic reaction

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18
Q

You suspect preseptal cellulitis, but upon further testing you find proptosis, paresis (partial paralysis- weakness) of III, IV, VI bilaterally, and decreased sensation of 1st (ophthalmic- upper eye lid, forehead, cornea, nose) and 2nd division (maxillary- teeth, mouth) of CN V, What is the differential diagnosis?

A

Cavernous sinus thrombosis

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19
Q

You suspect preseptal cellulitis, but find a rapid streptococcal cellulitis with CLEAR DEMARCATION, fever, and chills. what is the likely cause?

A

Erysipelas- acute, recurrent bacterial infection with large raised patches, especially on the face

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20
Q

We cannot just assume that preseptal cellulitis is in fact preseptal. in order to determine if the infection has spread to the septum, what tests can we do to rule out orbital cellulitis?

A

VA’s - loss = orbital cellulitis
EOM’s- pain= orbital cellulitis
Presence of proptosis
Direct/Consensual Pupillary Response - RAPD = Orbital cellulitis

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21
Q

A CT scan should be ordered if you suspect what alternatives? How should the CT look if your initial diagnosis of preseptal cellulitis is correct?

A

Significant trauma or Intra-Ocular Foreign Body. CT will show opacification strictly anterior to the septum

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22
Q

If the area appearing as preseptal cellulitis has an open wound or drainage, what tests need to be ordered?

A

gram stain and bacterial culture

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23
Q

Why would you palpate the perioribital area, head, and neck lymph nodes if you see what appears as preseptal cellulitis?

A

There could be a lymphoma or other lacrimal gland mass giving the appearing of preseptal swelling

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24
Q

So all signs lead to preseptal cellulitis, how do you treat it? Lets say the patient is a child older than 5, no fever? (2 choices) - dont worry about doses

A

Augmentin - Amoxicillin AB and Clavulanate – beta lactamase inhibitor) - 20 mg per kg divided into 3 doses

Cefaclor (ceclor) - 2nd gen cephalosporin - inhibits cell wall synthesis - 1 g/day

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25
Q

So all signs lead to preseptal cellulitis, how would you treat an adult patient? (3)

A

Augmentin or Ceclor or Dicloxacillin

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26
Q

All of your testing lead to a positive diagnosis of preseptal cellulitis in an Adult person who is known to be allergic to penicillins, how should you treat it?

A

Bactrim - Trimethoprim and sulfamethazole

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27
Q

Penicillins that can be used to treat Presptal Cellulitis

A

Flucloxacillin, Dicloxacillin, Cloxacillin

28
Q

Cephalosporins used to treat Preseptal Cellulitis - When are they the best to use?

A

Ceclor, Cephalexin, Cefadroxil, Cephradine

Best for Kids, especially with Gram + infection

29
Q

Macrolides that can be used to treat Preseptal cellulitis, when are they not good to be used?

A

Azithromycin Z-pack or Clarithromycin

Not good against Gram - bacteria like H. INFLUENZA

30
Q

Fluoroquinolones that can be used to treat Preseptal Cellulitis, When should they not be used?

A

Ciprofloxacin, Levofloxacin
Never in patients under 18 - causes tendonitis
Can also lead to secondary candida growth in females

31
Q

How long should antibiotic treatment be maintained for Preseptal Cellulitis treatment?

A

7-10 days

32
Q

All signs point to Preseptal Cellulitis, you wanted to prescribe augmentin or cefaclor but your patient is allergic to penicillins. upon further questioning he remembers that he is also allergic to drugs containing SULFA, what do you prescribe for treatment?

A

Erythromycin

33
Q

A man comes into your office because he was recently bit by his neighbors dog, and now his eyelid and adnexa are swollen. Tests confirm your suspicion for Preseptal Cellulitis. How do you treat it?

A

PenicillinG IV, Ampicillin/Sulbactam, Cefoxitin, or Clindomycin, because it is caused by Anaerobic bacteria - associated with mouths of humans or animals.

34
Q

A 4 year old child came in, and your testing confirmed Preseptal Cellulitis. The eyelid and adnexa are purplish-red in appearance, What do you do? Drugs used to treat and How long is the treatment for?

A

The patient’s infection is due to H. Influenza, so he should be hospitalized immediately and given IV antibiotics:
Ceftriaxone or Vancomycin for 2 weeks before switching to oral AB after showing improvement

35
Q

Your patient was recently hospitalized for Preseptal Cellulitis because he was not responding to oral tx. The gram staining showed gram positive bacteria. What should you suspect and how should the patient be treated?

A

MRSA should be suspected in patients with gram pos bacteria not responding to oral ABs, the patient should be given Vancomycin for 2 weeks then switched to an oral AB after showing improvement

36
Q

What Palliative - (meaning additional care that does not address the reason for the disease) - care should be used for Preseptal Cellulitis? What if there is secondary conjunctivitis?

A

Warm Compress 3x/day

Polymycin B/ Bacitracin (Polysporin) until gone

37
Q

A construction worker is presenting signs of Preseptal Cellulitis, and your testing confirms your diagnosis. Upon questioning, he tells you he wasnt wearing his helmet and took a rusty nail to the eyebrow area. What should you do in addition to treatment?

A

Tetanus toxoid treatment

38
Q

How often should you follow up with a patient you are treating for Preseptal Cellulitis?

A

Every day until improvement is showing (7-10 days), then every 2-7 days until gone

39
Q

Life threatening microbial infection with inflammation of the post septal aspect of eye lids

A

Orbital Cellulitis

40
Q

A diabetic patient with last reported hemoglobin A1C levels of 6.8% is tested positive for Orbital Cellulitis, what is the most likely precipitating factor for this condition?

A

Mucormycosis due to uncontrolled diabetes - normal A1C is 4-5.6%, normal blood sugar is 100- hyperglycemic environments favor immune dysfunction, resulting in opportunistic infections, like from the fungus Mucorales

41
Q

Most common routes of infections that cause orbital cellulitis - 3

A

Adjacent Sinuses or Teeth (gum disease or sinusitis) or through a penetrating lid injury

42
Q

Which bacteria are most likely responsible for orbital cellulitis in a patient who got punched in the face (local trauma)

A

S. Aureus and S. Pyogenes

43
Q

A patient with orbital cellulitis tells you she had a sinus infection last week. what bacteria do you suspect is the culprit for the infection?

A

Strep pneumoniae- most common pathogen associated with sinus infection

44
Q

A patient has fever, pain, and discomfort, with proptosis, and prominent lid edema and redness. you perform VA’s, EOM’s, Pupil test, and Color vision, what results would you expect?

A

Orbital Cellulitis
VA: Probably normal, but Reduced in severe cases
EOM: pain with movement and double vision due to a restricted muscle
Pupils: APD due to optic nerve compression
Color: red/greed defects due to optic disc manifestation

45
Q

A patient with HIV and DM has a fever, proptosis, diplopia, and inflammation. What action should you take?

A

The patient has orbital cellulitis, most likely mucormycosis. OC is a true emergency, and the patient needs to be refered to the ER and hospitalized with IV antibiotics

46
Q

A child comes into the office with a red swollen adnexa, proptosis, irritability, and fever. What do you prescribe for this patient? 2 options

A

EITHER: Vancomycin IV- 40 mg/kg in 3 doses
OR: Nafcillin IV - 150 mg/kg in 6 doses

WITH: Ceftriaxone IV 100 mg/kg in 2 doses

47
Q

An Adult comes into the office with a red swollen adnexa, proptosis, fever, diplopia. What do you prescribe for this patient? 2 options

A

EITHER Ceftriaxone IV - 1-2 g every 12 hrs
OR Nafcillin IV - 1-2 g vry 4 hours

WITH: Vancomycin - 1 g every 12 hrs

48
Q

Between Vancomycin, Nafcillin, and Ceftriaxone, which ones do all Adults get, which ones do all kids get, and which ones does each possibly get, respectively for orbital cellulitis?

A

KIDS : All get Ceftriaxone
All get either Vancomycin or Nafcillin

Adults: All get Vancomycin
All get either Ceftriaxone or Nafcillin

49
Q

A patient comes in with fever, diplopia, swollen red adnexa, and +APD. Positive HX for orbital cellulitis on 2 previous occasions. How do we treat him?

A

In addition to Vancomycin and Either Ceftriaxone OR Nafciliin, consider adding Metronidazole IV- 15 mg/kg loading dose, then 7.5 mg/kg every 6 hours

50
Q

What is another reason to add Metronidazole to Vancomycin/Ceft or Naf in an adult with orbital cellultis, besides chronic episodes?

A

Suspicion of Anaerobic bacterial infection as underlying cause

51
Q

Patient is presenting diplopia, proptosis, redness, and +APD, with red/green deficiency, Hx of fever in the past 2 days. Case history reveals allergies to Penicillins and Cephalosporin Antibiotics, what are your options for treatment?

A

EITHER Vancomycin IV - 1 gram/12 hrs
OR Clindamycin IV - 300 mg/6 hrs
PLUS Gentamycin IV - 2 mg/ kg loading, 1 mg/kg/8 hrs

52
Q

Patient is presenting diplopia, proptosis, redness, and +APD with red/green deficiency, and complaint of dry eyes . What do you need to do for the deficiency? What do you do for the dry eyes?

A
  1. Monitor the Optic Nerve function on follow up visits to ensure it is not worsening
  2. Prescribe Erythromycin to prevent corneal infection along with rewetting drops. The dryness is due to exposure keratopathy due to the proptosis, and makes the cornea susceptible to bacterial infection spreading from the eye lids
53
Q

After diagnosing a patient with orbital cellulitis, you order a CT scan. The patient brings the results back to you and you see the presence of a FB has lead to the infection of the ethmoid sinus and the growth of an abscess with suppuration. How do you proceed? what about after the selected treatment?

A

The patient needs surgery to decompress the orbit and open the infected sinus. Other cases would include compromised vision, or infection unresolved with antibiotics.

After, patient needs hospitalized for 24 to 36 hours to show improvement

54
Q

Term for a agressive, potentially fatal fungal infection of the orbit from the family of Mucorraceae. Tends to be in patients with diabetic ketoacidosis or immunocompromised. Inhaled spores gives URI, that spreads to sinuses, then orbit, then brain.

A

Mucormycosis - cause for orbital cellulitis

55
Q

While inspecting a patient with swollen face and orbital area, diplopia, and vision loss, you find proptosis, and Black Eschar on the nose and palate. You order a culture that reveals hyphae. Diagnose and Treat.

  1. Diagnose
  2. Drug
  3. Tests
  4. Further daily procedure
  5. Treatment for Black Eschar
  6. Treatment for devitalized tissue
  7. Last resort when unresponsive and severe
A
  1. Orbital Cellulitis caused by Mucormycosis
  2. IV Amphotericin B - 0.25 mg/kg over 3-6 hrs on 1st day- 0.5 mg/kg on 2nd day, 45-50 mg daily, duration depends on severity
  3. BUN and creatinine every day
  4. Packing and irrigation daily with amphotericin to the affected areas
  5. Excision of necrotic tissue
  6. Hyperbaric oxygen
  7. Exenteration - removal of affected organs if unresponsive and severe
56
Q

What is the most serious complication of Mucormycosis that results in vision loss

A

Retinal vascular occlusion - other complications include CN palsies and cerebrovascular occlusion

57
Q

Disease characterized by non-neoplastic, non-infectious, space-occupying, diffuse orbital inflammation. Caused by pleomorphic cellular inflammatory infiltration followed by fibrosis.

A

IOID - Idiopathic orbital inflammatory disease (idiopathic means spontaneous with unknown specific cause) - why the inflammation occurred that infiltrated the pleomorphic cells to cause fibrosis

58
Q

Is IOID unilateral or bilateral? for adults and children?

A

Unilateral in adults and possibly bilateral in children

59
Q

during case history, a patient tells you he has Wegener’s granulomatosis - a small and middle vessel cascultitis that affects lungs, kidneys, and other organs. The patient has signs of space occupying diffuse inflammation of the orbit. What is a likely diagnosis?

A

Idiopathic Orbital Inflammatory Disease - IOID - can also be caused with other systemic vasculitis conditions such as polyarteritis nodosa or lymphoma

60
Q

Where in the orbit could IOID possibly involve?

A

All soft tissues

muscles, lacrimal gland, cavernous sinus, peripheral portion of optic disc

61
Q

An adult patient presents signs of pain, prominent redness, diplopia, and decreased VA. Subjective refraction is +3.50 but was +1.50 last year. ONH looks swollen, and conjunctiva has chemosis. CT is ordered and reveals thickened poscterior sclera, orbital fat, lacrimal gland, and EOMs. Diagnose and Treat this patient.

  1. diagnosis
  2. tests for inflammation, protein breakdown, rule out vasculitis, mucormycosis, and wegeners
  3. Drug treatment, what to monitor
  4. If initial drugs dont work
  5. Follow up course
A
  1. Idiopathic Orbital Inflammatory Disease
  2. ESR and CBC inflammatory markers
    BUN to show protein break down - urea formation
    Creatinine to rule out Vasculitis
    FBS - to rule of mucormycosis
    ANCA if wegeners is suspected
  3. Treat with Prednisolone 100 mg 4x/day for inflammation and Rantidine 150 mg/ 2x/day to prevent ulcers, 1-2 weeks if responsive, monitor IOP closely
  4. low dose radiation if steroids dont work, or disease recurs , also order biopsy
  5. Re evaluate in 3 - 5 days,
62
Q

What can happen if a patient has severe prolonged inflammation of the orbit in a case of IOID that goes untreated?

A

prolonged inflammation leds to fibrosis of orbital tissues, causing a “Frozen Orbit” where the patient has ophthalmoplegia, ptosis, loss of VA due to optic nerve involvement

63
Q

Non specific inflamation in the cavernous sinus or superior orbital fissure that causes acute constant orbital pain. uncommon in people over 20 y/o, causes ophthalmoparesis due to palsies of CN3, 4, 6- most often, may involve pupil dysfunction, and trigeminal nerve involvement - V1- may cause forehead parastesia

A

Tolosa-Hunt Syndrome

64
Q

An 18 y/o patient is presenting ptosis and proptosis OD. During BIO you observe optic disc edema (why?) and DES (why?) and EOM’s reveal the right eye looking straight ahead while the patient is asked to look to the left along with report of pain and double vision (why?) While checking pupils, the sizes are 3 OD 5 OS in bright and 7 OD and 6 OS in dim. (Why?) Diagnose and Treat.

A
  1. Tolosa-Hunt Syndrome - can be due to idiopathic orbital psuedotumor
  2. orbital involvement in this case
  3. loss of corneal reflex if V1 is involved, less stimulus for blinking causing dry eye
  4. Inability to abduct the affected eye due to CN VI involvement
  5. Pupil involvement due to affected sympathetic fibers of CN III, causing Horners, which indicates possible inflammation at cavernous sinus
  6. Treat with steroids, Prednisolone
65
Q

Rare multisystem autoimmune disease of unknown etiology, marked by necrotizing granulomatous inflammation and pauci-immune vasculitis (little sign of hypersensitivity) in small and medium blood vessels of lungs, sinuses, nasopharynx. may be present with bilateral orbital inflammation due to sinus pathology.

A

Wegener’s Granulomatosis

66
Q

Patient comes in with proptosis, and finding of ophthalmoplegia during EOM’s. You palpate the lacrimal gland that appears swollen to find dacryadenitis to rule out Septal cellulitis. Diagnose, test, and treat. Other signs that would also indicate orbital invovlement?

A
  1. Wegener’s Granulomatosis
  2. cANCA test - anti neutrophilic cytoplasmic antibody test found in 90% of active disease cases
  3. Cyclophosphamide (Cytoxan) to suppress immune system, and steroids. Resistant cases require cyclosporine, azathioprine, antithymocyte globulin, or plasmapheresis
    If severe cases with orbital involvement, orbital decompression surgery
  4. Necrotizing scleritis, peripheral ulcerative keratitis, occlusive retinal periarteritis, orbital congestion, nasolacrimal duct obstruction can all indicate involvement of orbit in Werner’s

Disease 1 (8 decks)

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