Orbital Trauma and Cellulitis

Question 1

Should you remove penetrating objects?

Answer 1

Avoid removing any penetrating objects, support the object and transport supine.

Question 2

Why is it important to measure acuity as soon as possible in orbital trauma?

Answer 2

Measure acuity as soon as possible to get a baseline.

Question 3

What should you examine in orbital trauma and how should you do it if its too painful?

Answer 3

If opening the eyelid is difficult or painful give some anaesthesia eyedrops to allow opening easier and examination. Make sure to examine lids, conjunctiva, cornea, sclera, anterior chamber, pupil, iris, lens, vitreous, fundus and eye movement.

Question 4

What investigations should be done in orbital trauma?

Answer 4

Irregular pupils indicate globe rupture and RAPD do not bode well for sight recovery.
CT head – avoid MRI as unknow FB could be magnetic

Question 5

How should orbital burns be managed?

Answer 5

Treat promptly, give anaesthetic drops every 2mins and wash out with clean water in copious amounts whilst the specific antidote is being sought. Remember alkali burns are more serous than acid but either way refer promptly.

Question 6

How should intraocular bleeds be managed?

Answer 6

Must get expert help, blood is usually seen in the anterior chamber (hyphaema). A little will clear spontaneously but if its gushing then evacuation may be required. Even small bleeds should be referred as they could signify more serious injury.

Question 7

What is a blow out fracture?

Answer 7

These occur due to blunt trauma to the orbital area causing a sharp peak in intraocular pressure. This will result in fracture of the inferior orbit (maxilla) into the maxillary sinus. This will cause tethering of the inferior rectus muscle and inferior oblique causing diplopia.

Question 8

How should a suspected blow out fracture be investigated?

Answer 8

Testing sensation of the lower lid skin – if gone this indicates infra-orbital nerve injury and can confirm a blow-out fracture.
CT scan will show blood and potentially muscle in the maxillary sinus

Question 9

How are blow out fractures managed?

Answer 9

Fracture reduction and muscle release – delayed in adults to allow inflammation and oedema to calm down
In children urgent treatment may be required if a trap door fracture has occurred. This is indicated by up gaze limitation and oculovagal response – vagal response when applying orbital pressure

Question 10

What is a retrobulbar haemorrhage?

Answer 10

Can occur after any direct trauma to the orbit including surgery. Results in a compartment syndrome and risks complete loss of vision.

Question 11

How does retrobulbar haemorrhage present?

Answer 11

Presents as a tight swollen eyelid, unilateral fixed dilated pupil, reduced eye movement and profound loss of vision.

Question 12

How should retrobulbar haemorrhage be managed?

Answer 12

Requires urgent canthotomy and cantholysis

Question 13

What is orbital cellulitis?

Answer 13

This is an ophthalmic and life-threatening emergency. Occurs as a result of infection of soft tissues posterior to the orbital septum. Complications – subperiosteal and orbital abscess. Intracranial involvement – abscess, meningitis and venous sinus thrombosis.

Question 14

What can cause orbital cellulitis?

Answer 14

Paranasal sinus infection (especially ethmoid)
Eyelid infection
Dental injury/infection
External ocular infection
Lack of Haemophillus influenzar B vaccination

Question 15

What organisms are usually involved in orbital cellulitis?

Answer 15

Staphylococcus aureus
Streptococcus pneumoniae
Haemophilus Influenzae B

Question 16

What are the clinical features of orbital cellulitis?

Answer 16

Younger child 
Inflammation in the orbit 
Fever
Lid swelling 
Reduced eye mobility and diplopia 
Painful eye movements
Exophthalmos (proptosis) 
Conjunctival swelling (chemosis)

Question 17

How should suspected orbital cellulitis be investigated?

Answer 17

FBC
Acuity 
Pupils - RAPD
Colour vision 
Blood cultures and microbial swab

CT with contrast to confirm abscess. Indications – central signs, can’t assess vision, gross proptosis, bilateral oedema, ophthalmoplegia, deteriorating acuity or colour vision or no improvement at 24 hours or pyrexia at 36 hours.

Question 18

How is orbital cellulitis managed?

Answer 18

Refer to ophthalmology urgently

IV antibiotics and abscess drainage if indicated

Question 19

What is preseptal or periorbital cellulitis?

Answer 19

Infection anterior to the orbital septum.

Question 20

What are the common causes of preseptal cellulitis?

Answer 20

Sinusitis or facial skin lesions such as insect bites or trauma.

Question 21

Which organisms are usually involved in preseptal cellulitis?

Answer 21

Staphylococcus aureus and epidermidis

Streptococcus pneumoniae

Question 22

What are the clinical features of periorbital cellulitis?

Answer 22

Younger patient
Acute erythematous swelling of the eyelid
Partial or acute ptosis of the eye due to swelling
Absence of painful eye movements, diplopia and visual impairment.

Question 23

What investigations should be done in suspected preseptal cellulitis?

Answer 23

FBC
Swab of area and discharge
Contrast CT if in any doubt

Question 24

How is preseptal cellulitis managed?

Answer 24

If any doubt treat as orbital cellulitis

Oral antibiotics such as Co-amoxiclav

Question 25

What signs and symptoms differentiate orbital cellulitis from preseptal cellulitis?

Answer 25

Reduced visual acuity
Proptosis
Ophthalmoplegia