Understanding Orbital Cellulitis: Causes, Symptoms, Management

1. Diseases of the orbitOrbital Cellulitis Dr. Ayesha S Abdullah 19.08.2016

2. Learning objectives By the end of the lecture the students should be able to • Differentiate between preseptal and true orbital cellulitis • Explain why it is considered to be an ocular emergency • Describe the causes, • Explain the clinical presentation, complications & line of management of orbital cellulitis

3. Orbital cellulitis • Preseptal cellulitis • True orbital cellulitis

4. Preseptal orbital cellulitis • Infection of the subcutaneouss tissue anterior to the orbital septum ( lids) • Causes: • Trauma; lid laceration/ insect bite • Spread from local infection; stye/ dacrocystitis, dental infection • Spread from remote infection; haemotogenous spread from middle ear/ Upper Respiratory Tract

5. Preseptal orbital cellulitis • Clinical presentation • Symptoms; History of predisposing factor, pain & swelling of the lid, mild fever • Signs; red swollen tender lids sometimes the lids may be difficult to open. Important negative signs are: • Eye itself is normal at the most might be mildly congested • Visual acuity is normal • No proptosis • No ocular motility problem • Normal pupils

6. Preseptal orbital cellulitis • Complications • True orbital cellulitis • Lid abscess • Cavernous sinus thrombosis

7. Management of Preseptal orbital cellulitis • Symptomatic; analgesics & NSAIDS • Specific: • Very severe infections may require Adults: 250 – 500 mg oral Co-amoxiclav qds/ tds depending on severity of infection. • Children: 20-40mg/kg/day oral co-amoxiclav over 24h in three divided doses. • benzylpenicillin 2.4-4.8 mg I/M 6 hourly in severe infections • Lid abscesses should be drained • Third generation cephalosporins in penicillin allergy

8. Orbital cellulitis • Infection of the soft tissues behind the orbital septum ( deeper to lids) • Ocular emergency , could be life threatening • Most frequent pathogens are; • Strept. Pneumoniae , • Staph aureus, • Strept. Pyogenes & H influenzae - (under 5yr)

9. Causes • Spread from the sinuses; mostly ethmoidal in children & young adults • Extension from preseptal cellulitis • Local spread; dacrocystitis, dental infection, facial infection, infection of the eyeball ( panophthalmitis etc) • Haemotogenous spread • Post- traumatic; accidental/ surgical

10. Clinical presentation • Symptoms; rapid onset painful swelling of the lids & protrusion of the eye, fever, malaise & visual loss ; history of risk factors • Signs; moderate to severe swelling of the lids, reduced visual acuity, proptosis,red eye with chemosis of the conjunctiva, abnormal & painful EOM & pupillary response

14. Management • Admit • Symptomatic; antipyretic, NSAIDS • Specific ; hospitalization & antibiotic therapy • Ceftazidime/ Cftriaxone/ Cefuroxime 1 g tds , I/V • Mteronidazole 500mg tds, PO / IV • Vancomycin in case of allergy to the above mentioned • Surgical intervention in case of local abscess or unresponsive cases • Consultation with ENT specialist, neurosurgeon & paediatrician if required

15. Complications Ocular; corneal damage( exposure),raised IOP, vascular occlusions, optic nerve damage, endophthalmitis Intracranial; meningitis, brain abscess, cavernous sinus thrombosis Orbital abscess

18. Case #1 A 1 year old child presented to the OPD of department of ophthalmology with the complaint of a swollen right upper lid for the last two days. On examination the lid was red, warm & tender to touch. His visual acuity was normal, the eye had mild conjunctival redness, the pupil was normal and the ocular movements were also normal. Watch the photograph….

20. Some questions • Is the condition confined to the lids or has it involved the eyeball? • Why do you think so? • What more information would you like to have before making a diagnosis?

21. Some more information……… • The child had a history of insect bite on the lid two days ago, the swelling increased thereafter. The insect bite mark was visible • There was no history of trauma or symptoms suggestive of sinusitis • His temperature was 99.80 F

22. Some more questions • What should be the management, keeping in mind the nature of the problem? • Is there any role of health education in this case? Let us see an other case……..

23. Case #2 • A seven year old child was brought the OPD of the department of ophthalmology with a history of swollen left upper lid for the last 5 days. He also had fever for the last two days. On examination the child had a grossly swollen lid. The doctor had difficulty in opening the lid for examination of the eye. The visual acuity was 6/6 OD & 6/18 OS. The lid was warm and tender. The eye was moderately proptosed with conjunctival chemosis. The pupil was slow to react to light and the ocular movements were painful & limited. The temperature was 1010 F & the child looked generally unwell……..

24. Some questions…. • Is the condition confined to the lids or has it involved inner orbit? • What more information should we ask for to get an idea about the cause of the problem?

26. The child had a history of recurrent flu and upper respiratory tract infections. He had history of blocked nose and thick greenish nasal discharge was noted on examination. • The child was put on intravenous antibiotics but didn’t get better • Why?

27. The antibiotics were changed to intravenous ampicillin/sulbactam and after 5 days were changed to oral amoxicillin/clavulanic acid for a total of 14 days of antibiotics.

28. Some more questions • What should be the management, keeping in mind the nature of the problem? • What do you think can be done with the abscess? • Is there any role of health education in this case? • ..

29. Conclusion about the two cases • What is the difference between the two cases? • We consider the second case an ocular emergency, why? • Why did the subperiosteal abscess form in the second case? • What other complications could happen in the second case?

30. Let us summarize • Preseptal orbital cellulitis & orbital cellulitis are both infections. • It is more common in children • The route of infection could be from the nearby infectious focus like infected sinuses, skin wound or spread of infection via blood • The most common cause especially in children is ethmoidal sinusitis

31. Both preseptal and orbital cellulitis may have: • Fever • Eyelid swelling • Pain • Red eye • Child is ill-appearing

32. Orbital cellulitis signifies spread of inflammation to the posterior orbital contents that is the eyeball, extraocular muscles: helpful signs to distinguish it are:- • Proptosis • Decreased visual acuity ( may be normal in the beginning) • Red eye with conjunctival chemosis of moderate to intense congestion • Painful limited eye movements • Afferent pupillary defect

33. Prior to the availability of antibiotics, patients with orbital cellulitis had a mortality rate of 17%, and 20% of survivors were blind in the affected eye. However, with prompt diagnosis and appropriate use of antibiotics, this rate has been reduced significantly • blindness can still occur in up to 11% of cases. Orbital cellulitis due to methicillin-resistant Staphylococcus aureus can lead to blindness despite antibiotic treatment.