Orbital cellulitis Flashcards
What are the two types of cellulitis around the eye?
Peri-orbital OR pre-septal cellulitis - inflammation and infection of the superficial eyelid anterior to the orbital septum
Orbital cellulitis - orbital soft tissue infection behind the orbital septum, not involving the globe; warrants hospital admission and has high morbidity
What are some risk factors for orbital and peri-orbital cellulitis?
Superficial tissue injury - e.g. insect bite or chalazion
Bacterial sinusitis - may occur secondary to this in children. Mucor or invasive Aspergillus in diabetics and immunocompromised.
Haematogenous spread - from primary infection e.g. from pneumonia
Young age - more common in children
M>F
Lack of Haemophilus influenzae type b (Hib) vaccination
What are the signs and symptoms of pre-septal and orbital cellulitis?
Orbital cellulitis:
- ophthalmoplegia - ?RAPD from increased intra-ocular pressure
- proptosis
- visual disturbance
- pain
- malaise
- headache
- fever
- nausea/vomiting - if meningeal involvement
- chemosis
Peri-orbital cellulitis:
- redness around eyelid without significant pain, swelling, tenderness or fever
- eyelid oedema
- partial or complete ptosis from swelling
- absent orbital signs
Both:
- ? sinusitis,
- ? infected tooth
- ?enlarged lymph nodes
- ?stye/chalazion
- ? insect bie
- ? penetrating injury
What investigations should be done to diagnose pre-septal/orbital cellulitis?
Ophthalmological assessment - vision, RAPD, dysmotility, oedema, erythema.
Bloods - look at inflammatory markers
Swab discharge
Contrast CT orbit - may help differentiate preseptal and orbital cellulitis; should be done in all patients.
Blood culture - determine organism
If meningeal signs develop: LP
What is the management of pre-septal cellulitis?
- ALL cases referred to secondary care for assessment
- Empirical antibiotics 7-10days - usually oral cefotaxime or cefuroxime; in adherent children or adults consider oral abx; but most children receive 2-5 days IV abx before switching to oral
- Incision and drainage - if abscess present
Children should be admitted for observation
What is the management of orbital cellulitis?
Admit to hospital
IV antibiotics - e.g. metronidazole and cefuroxime; broad spectrum initially then targeted
Incision and drainage - if abscess present
+/- Lateral canthotomy and cantholysis - may be necessary to reduce intra-ocular pressure
+/- Nasal decongestant - to reduce nasal oedema and improve drainage e.g. ephedrine 0.25% nasal drops
What are the complications of pre-septal or orbital cellulitis?
Sub-periosteal abscess
Cavernous sinus thrombosis
Intracranial abscess
Subsequent vision loss
Death
What is the prognosis with pre-septal vs orbital cellulitis?
Clinical improvement usually seen within 24-48hrs of abx in pre-septal and orbital cellulitis
In peri-orbital cellulitis it is rare for an immunocompetent patient to progress to orbital cellulitis
If there are bilateral orbital signs, what should you suspect?
Cavernous sinus thrombosis
What are the clinical features of cavernous sinus thrombosis?
Causes: sinusitis, neoplasia, trauma
- Periorbital oedema
- Ophthalmoplegia - 6th nerve damage before 3rd and 4th
- Trigeminal 5th nerve invovlement may cause hyperaesthesia of upper face and eye pain
- Central retinal vein thrombosis
What are the most common bacterial causes of peri-orbital/orbital cellulitis?
- Staph aureus
- Staph epidermidis
- Streptococci
- Anaerobic bacteria
- Haemophilus influenzae (orbital)
How common is preseptal cellulitis?
80% of patients are under 10yrs old
Median age is 21 months
More common in winter due to more URTIs
If a patient with orbital cellulitis is having viscid, dark brown-black nasal discharge, what treatment should be considered?
Amphotericin B
