Week 3 - Cellulitis and Thyroid

Question 1

What are the 2 types of Cellulitis?

Answer 1

• Preseptal
• Orbital

Question 2

What is Preseptal cellulitis and its causes?

Answer 2

• Infection of orbital tissues anterior to orbital septum
• Causes
- Trauma around eye
- spread of infection from nearby structures e.g. dacrocyctitis, hordeolum, recent eye surgery
- spread of remote infection .g. upper respiratory tract infection, impetigo, recent surgery around eye

Question 3

what are Preseptal cellulitis signs and symptoms?

Answer 3

• Symptoms:
- Unilateral
- Red tender swelling around eye
- Unwell px (fever, malaise, irritable child)

• Signs:
- Lid edema, warmth, tenderness, ptosis
- Fever

Question 4

how is Preseptal cellulitis managed differently by optometrists and ophthalmologists?

Answer 4

• Management by community optometrist
- CMG: “Emergency (same day) referral to ophthalmologist or A&E Department, no intervention”
• Management by hospital ophthalmologist
- confirmation of diagnosis, CT scan
- systemic antibiotics

Question 5

What is orbital cellulitis and its causes?

Answer 5

• Infection of orbital tissues behind the orbital septum

• Causes
- spread of remote infection
- sinus infection (most common)
- mid-facial infection
- dental infection
• post-trauma (48-72hrs after)
• post-surgical

Question 6

what is orbital cellulitis symptoms and signs?

Answer 6

• Symptoms & Signs
- Swollen, red, warm and tender eyelids
- Proptosis
- Restricted and painful eye movements
- Optic nerve dysfunction (advanced)
- pupil reactions (RAPD)
- VA
- colour vision
• Rapid onset
• Severe malaise & fever

Question 7

how is orbital cellulitis managed differently by optometrists and ophthalmologists?

Answer 7

• Management by community optometrist:
- CMG: “Emergency (same day) referral to in tethalmologist or AGE Department, no intervention

Management by hospital ophthalmologist
• confirmation of diagnosis, CT scan, blood tests
• admission to hospital
• systemic antibiotics (IV)

Question 8

How does proptosis, motility, acuity, colour vision and RAPD Differ between preseptal and orbital cellulitis?

Answer 8

• Proptosis: Absent vs present
• Ocular motility: normal vs painful, restricted
• Visual acuity: normal vs reduced in severe
• Colour vision: normal vs reduced in severe
• RAPD: normal vs reduced in severe

Question 9

What are the 2 stages of pathogenesis for thyroid eye disease?

Answer 9

2 stages of pathogenesis:
• Inflammation of EOMs
- Enlargement up to 8x
- Fibrosis
• Inflammatory cellular infiltration
- Increase in volume of orbital structures
- Elevation of intra-orbital pressure

Question 10

What are the 2 stages of disease development for thyroid eye disease?

Answer 10

• Congestive
- Red, painful eyes
- 10% have long-term complications
• Fibrotic
- White and painless
- Motility defect

Question 11

What are the 5 clinical manifestations of thyroid eye disease?

Answer 11

• Soft tissue involvement
• Lid retraction
• Proptosis
• Optic neuropathy
• Restrictive myopathy

Question 12

What things should be considered when dealing with thyroid eye disease?

Answer 12

• Managed by community optometrists?
• Management by eye-care practitioner in hospital?
• Always consider graves disease/thyroid eye disease

Question 13

What are the signs and symptoms of thyroid eye disease?

Answer 13

Signs:
• hyperaemia/conjunctival injection
• swelling
• superior limbic keratoconiunctivitis.
• dry eye

Symptoms:
• Grittiness
• Photophobia
• Lacrimation
• Discomfort

Question 14

How is thyroid eye disease treated?

Answer 14

Management of dry eye

Question 15

What is lid retraction and how common is it?

Answer 15

Occurs in 50% with graves

Pathogenesis:
• Fibrotic contracture of levator
• Secondary overaction of levator-superior rectus complex in response to fibrosis of inferior rectus
• Humorally-induced overaction of Muller muscle

Question 16

What are the signs and symptoms, and the treatment if lid retraction?

Answer 16

Symptoms/signs
• Upper lid higher than normal, lower lid lower than normal

Treatment
• Mild: none, may spontaneously resolve
• Surgery considered if stable
• Treat the associated dry eye (see the dry eye CMG)

Question 17

What types of proptosis are there, what can it cause and whats the treatment?

Answer 17

Types:
• Axial
• Unilateral or bilateral
• Symmetrical or asymmetrical

Causes:
• Exposure keratopathy
• Corneal ulceration
• Infection

Treatment:
• Treat the dry eye (see dry eye CMG)
• Treat the corneal problem (see keratitis CMGs)

Question 18

What is Restrictive myopathy and its treatment?

Answer 18

• 30-50% have ophthalmoplegia (may be permanent)
• IOP may increase when moving eye or in primary position
• All of EOMs may be affected —> diplopia
• In order of most commonly affected: Elevation; Abduction; Depression; Adduction

• Treatment
- Referral for surgery or bolulamin toxin

Question 19

What is optic neuropathy signs and treatment?

Answer 19

• Uncommon but serious

Signs:
• Loss of vision
• RAPD
• Field defects
• Increased IOP
• Usually normal appearance of disc

Treatment:
• Ophthalmologist treats with steroids