Midterm 2- Preseptal vs Orbital Cellulitis Flashcards
Preseptal Cellulitis
Is a relatively common eyelid infection that involves the periorbital tissue anterior to the orbital septum
preseptal acute eye lid
Edema
Erythema
Preseptal Cellulitis causes
- Local spread of URI Spread of eyelid infection
- Following trauma to the eyelids
- Spread of a sinusitis or dacryocystitis
- Following an insect bite to the eyelids
preseptal risk factors
Hordeola Chalazia Bug bites Trauma-related lesions Lesions caused by a recent surgical procedure near the eyelids Lesions caused by oral procedures Dacryocystitis
Hordeolum
Aka stye:
Swollen eyelid
Senesitive to paplitation
External hordeolum
Infection of the gland of Zeis
Internal hordeolum
Infection of a meibomian gland
what is the cause of 90-95% of hordeolums
Staphylococcus aureus
Chalazion
Aka meibomian gland lipogranuloma or a meibomian cyst.
Painless
Hard on palpitation
No tenderness or inflammation
how does chalazian occur
invasion of the organism to the subcutaneous tissue through an abrasion or inflammatory ulceration
what is a usual cause of preseptal cellulitis
URI is usually the cause, if no evidence of trauma or local lid infection is found.
Recent history of URI with or without sinusitis is usually found.
preseptal offending pathogens
Staphylococcus aureus
Staphylococcus epidermidis
Streptococcus species
Haemophilus influenzae
h flue was leading cause intil 1985 not now b/c of vaccine
what is the most common cause of preseptal in children in the us
streptococcus pneumoniae
PC associate with or secondary to
TB Chlamydial conjunctivitis Juvenile Idiopathic Arthritis Acinetobacter MARSA (methicillin resistant Staphylococcus aureus)
what is important for preseptal cellulititis
You MUST Rule out Orbital Cellulitis!!!
PC subjective
Red swollen eyelid Pain Epiphora Red Eye (Conjunctivitis) May have a mild to moderate fever
PC objective
Acute eyelid erythema, Conjunctival injection Tenderness to touch Pain (lid pain) Eyelid edema
what are not objective findings in PC
NO APD NO PROPTOSIS NO PAIN ON EOMs NO EOM restriction Usually Normal VAs
PC diagnosis
Careful examination of eyelid tissue for:
- Puncture wound
- Trauma
- Eye lid infection
- Infectious lesion of the skin
what population is affected in pc the most
It is primarily a pediatric disease
Approximately 80% of patients younger than 10
what is present in both pc and oc
Lid swelling and inflammation is present in both preseptal and orbital disease.
why do you need an orbital ct
if the eyelids cannot be separated to evaluate for
Proptosis
Limited ocular motility
VA loss
CT recommended if
- Orbital involvement cannot be ruled out on clinical examination alone
- Disease progression despite antibacterial therapy.
- Young kids where a reliable exam is difficult.
Pc tx
Empiric Tx for adults and older children:
Amoxicillin/clavulanate (Augmentin)
Mild to moderate: 500/125 mg PO tid
for 10 days
Severe: 875/125 mg PO bid
for 10-14 days
po= by mouth
covers strep but not as effective as MRSA
pc tx mild
Empiric Tx for adults and older children:
Augmentin
PC tx For children older than 5 (<40Kg)
: 25 to 45 mg/kg/day p.o. in two divided doses,
maximum daily dose of 90 mg/kg/day
PC
Empric TC for younder children
Amoxicillin/clavulanate (augmentin)
<40 kg ~ 88lb
pc tx <3 months:
Augmentin)
<3 months: 30 mg/kg PO divided q12h X 10 days
Consult with pediatrician on infants and kids!!
pc tx >3 months
45 mg/kg PO divided q12h
or 40 mg/kg divided tid X 10 days
Older than 5
Must F/U in 24 hrs!!
what tx
Covers S aureus (including MRSA), S pneumoniae, most other streptococci, and anaerobes [7] but has poor H influenzae coverage.
clindamycin
Adult: 600 mg PO q8h for 10-14 days
Pediatric: 30-40 mg/kg/day PO divided q8h for 10-14 days (maximum of 1.8 g/day)
other tx for pc
Cefpodoxime:
Adults
200 mg p.o. q12h
Children
10 mg/kg/day p.o. in two divided doses for children,
maximum daily dose of 400 mg;
pc Treatment: If allergic to PCN
Trimethoprim/sulfamethoxazole (eg Bactrim)
Adults:
160-320 mg trimethoprim with 800-1600mg sulfamethoxazole p.o. bid X10 days
Children (older than 5)
8-12 mg/kg/day trimethoprim with 40-60 mg/kg/day sulfamethoxazole, p.o. in two divided doses X10 days
or
Moxifloxacin 400 mg p.o. daily (contraindicated in children)
pc Treatment: If exposure to methicillin-resistant Staphylococcus aureus (MRSA) is suspected, then:
adults
Adults:
160 to 320 mg trimethoprim with 800 to 1,600 mg sulfamethoxazole (one to two double-strength tablets) p.o. b.i.d. for adults.
pc Treatment: If exposure to methicillin-resistant Staphylococcus aureus (MRSA) is suspected, then:
children
Trimethoprim/sulfamethoxazole: 8 to 12 mg/kg/day trimethoprim with 40 to 60 mg/kg/day sulfamethoxazole p.o. in two divided doses for children;
or
Doxycycline: 100 mg p.o. b.i.d (contraindicated in children, pregnant women, and nursing mothers).
pc tx if severe
Hospitalize for i.v. antibiotics IF: Moderate to severe cellulitis Patient is toxic Patient may be _noncompliant\_\_\_ Child younger than 5 years No noticeable _improvement\_\_ or worsening after a few days with Tx.
pc I.V examples
- Ampicillin/sulbactam (Unasyn)
- Ceftriaxone (e.g.Rocephin)
- Vancomycin, if methicillin-resistant S. aureus is suspected.
pc topical Treatment:
- Warm compresses to the inflamed area t.i.d. p.r.n.
- Polymyxin B/bacitracin ointment to the eye q.i.d. if secondary conjunctivitis is present.
- Nasal decongestants if sinusitis is present.
Orbital Cellulitis
Is an infection of orbital soft tissue posterior to the orbital septum
OC epidemilogy
- More common in children than in adults.
- Median age of children hospitalized with orbital cellulitis is 7-12 years
- In children, twice as common in males than females
oc in adults
- Equal in males and females
- Except for cases caused by MRSA, which are more common in females by a 4:1 ratio.
oc causes
- Extension of an infection from the periorbital structures, sinuses and teeth.
- Infection of the orbit following trauma or surgery of the eyelid
- Hematogenous spread of bacteremia.
is there vision loss wit oc
yes, 11% of cases
what is the most cases caused by in oc
ethmoid sinusitis
must ask about recent dental work
what can happen if oc not treated
sinus thrombosis and meningitis which can be life threatening!!!
oc offending pathogens
Staphylococcus aureus
Streptococcus species
Haemophilus influenzae type B.
oc fungal offenders
Mucor
Aspergillus
oc subjective
Red, swollen eye/eyelid Fever Malaise History of recent URI or sinusitis Headache, sinus Tooth pain
oc subjective
Red eye. Pain on eye movement Tender to the touch Decrease vision Double vision
oc Objective:
-Decreased vision
-Lid edema and erythema
proptosis*
-Conjunctival chemosis
-Restriction on EOMs*
-Pain on eye movement
-May have elevated IOP
- Red discoloration of the eyelid
- Conjunctival chemosis & hyperemia
- Nasal discharge maybe present
- Optic disc edema
- Afferent Pupillary Defect (+ APD) opthalmoplegia and proptosis are key findings of orbital cellulitis
oc history
- Trauma or surgery?
- Ear, nose, throat, or systemic infection?
- Tooth pain or recent dental abscess?
- Stiff neck or mental status changes?
- Diabetes or an immunosuppressive illness?
oc Work up:
Complete ophthalmic examination: Look for -Afferent pupillary defect (APD) -Limitation of or pain with EOMs, -Proptosis, -Elevated IOP, -Decreased color vision, -Decreased skin sensation, or Optic nerve or fundus abnormality.
Check vital signs, mental status, and neck flexibility.
what is essential for oc work up
Imaging is ESSENTIAL!!!
- Hi resolution CT scan with contrast and axial and coronal views.
- MRI may be needed to evaluate for cavernous sinus disease.
orbital involvement on CT
stage 1
Preseptal cellulitis
orbital involvement on CT
stage 2
Inflammatory orbital edema
orbital involvement on CT
stage 3
Subperiosteal abscess
orbital involvement on CT
stage 4
Orbital abscess
orbital involvement on CT
stage 5
Cavernous sinus thrombosi
oc cbc count
Count > 15,000
Blood culture.
Culture material from sinuses or orbital abscess.
Needle aspiration of orbit is contraindicated
oc tx
Hospitalization!!!
-Medical management:
IV broad spectrum antibiotics are started STAT until pathogen is identified.
-IV abs are used for 1-2 wks followed by oral Tx for 2-3 wks.
-Ampicillin-sulbactam is a good initial choice for broad-spectrum coverage
oc tx anaerobc
Penicillin G, cefoxitin, metronidazole, clindamycin, or chloramphenicol should be considered for suspected anaerobic infections.
oc tx if MRSA
Vancomycin, cefotaxime, trimethoprim-sulfamethoxazole and clindamycin can be effective
oc fungal
potentially lethal
Principal organisms involved
Mucor and Aspergillus, require the use of antifungals.
Tx with:
Amphotericin B deoxycholate (AmBisome)
oc Surgical drainage:
- If poor response to appropriate Tx in 2-3 days.
- If there is a decrease in VAs
- If a positive APD develops
- Progression of proptosis despite tx
- Abscess size doesn’t decrease in 2-3 days
- If brain abscess develops & doesn’t respond to Abs Tx then craniotomy is indicated.
oc consultation
Pediatrician, internist or family physician
Infectious disease specialist
ENT if sinusitis is the causative factor
Summary
- PC is more common than OC
- Proptosis and ophthalmoplegia can DDx the two.
- Most PC will respond to PO Abs on an outpatient basis
- OC needs hospitalization, IV Abs, Imaging
- Abs should cover G+ and G-.
