Orbital and pre-orbital cellulitis

Question 1

What is pre-orbital cellulitis?

Answer 1

Infection occurring anterior to the orbital septum

Question 2

What is orbital cellulitis?

Answer 2

Infection occurring posterior to the orbital septum

- Fat and muscle within the orbit

Question 3

Which population is orbital cellulitis more common in?

Answer 3

Children

Question 4

Which cellulitis is sight threatening?

Answer 4

Orbital

Question 5

What causes orbital cellulitis?

Answer 5

Spreading of local infection such as from the paranasal sinuses
Extension of peri-orbital cellulitis
Dental infection

Question 6

What are the typical symptoms of orbital cellulitis?

Answer 6

Blurred vision 
Erythema and swelling round the eye 
Painful eye movements
Change in colour vision 
Fever

Question 7

Describe the clinical examination for orbital cellulitis

Answer 7

Nasal exam - ipsilateral discharge/mucus
Oral cavity exam - oral hygiene, dental disease
Eye and vision exam - visual fields, VA, colour vision, RAPD, light reflexes, ptosis
Neuro exam - cranial nerves and assess for meningism

Question 8

Describe some clinical findings in orbital cellulitis

Answer 8

Severe eye redness and swelling
Fever
Painful eye movements
Reduced visual acuity or visual fields
Proptosis
RAPD
Chemosis 
Altered colour vision

Question 9

What may bilateral eye signs in orbital cellulitis indicate?

Answer 9

Cavernous sinus thrombosis

Question 10

What investigations does orbital cellulitis require?

Answer 10

FBC, CRP, Lactate, blood cultures, microscopy, culture and sensitivity swabs, CT orbit, sinuses and brain, MR venogram (cavernous sinus thrombosis). LP if meningitis suspected

Question 11

What are the common causative organisms of orbital cellulitis

Answer 11

Staphylococcus
Streptococcus
Haemophilus

Question 12

How should orbital cellulitis be managed?

Answer 12

Urgent referral to ENT and ophthalmology
IV antibiotics for 7-10 days
Surgical management - if orbital collection seen on imaging - evacuation of pus or drainage of paranasal pus may be required

Question 13

What is chandlers classification used for?

Answer 13

Anatomically classifies orbital complications of acute rhinosinusitis

Question 14

Describe the grades of chandlers classification

Answer 14

Grade 1 - pre-septal cellulitis
Grade 2 - orbital cellulitis
Grade 3 - Subperiosteal cellulitis 
Grade 4 - Intraorbital abscess
Grade 5 - cavernous sinus thrombosis

Question 15

How should Grade 5 cellulitis be treated?

Answer 15

Anticoagulants
Antibiotics
Surgical management

Question 16

List some complications of orbital cellulitis

Answer 16

Cavernous sinus thrombosis
Loss of vision 
Intracerebral abscess 
Meningitis
Death

Question 17

What causes pre-septal cellulitis

Answer 17

Injury/insect bite

2ndary to infection (URTI/sinusitis)

Question 18

Give the typical presenting complaint of pre-septal cellulitis

Answer 18

Pain, redness and swelling of eyelid

Question 19

Describe the clinical examination of pre-septal cellulitis

Answer 19

Exclude orbital cellulitis - check VA, colour vision, visual fields and eye movements 
Red, swollen eye
No pain on eye movements
VA and fields normal 
Systemically well

Question 20

Describe the management of pre-septal cellulitis

Answer 20

If suspicion of orbital cellulitis - urgent ophthalmology/ENT review
Oral co-amoxiclav (clindamycin if penicillin allergic) and safety netting