1. Interesting Case Rounds
Nadim J Lalani PGY 4

2. ?

3. "Pinkeye" (seventh South Park episode aired October 29, 1997).
Mir space station crashes into (and kills) Kenny at a bus stop October 30.
Kenny is taken to morgue
accidentally embalmed with fluid containing Worcestershire sauce turns Kenny into a zombie.
Kenny breaks out of the morgue  bites two coroners.
The morgue workers on exam:
temp 55°F, pulseless, eyes are puffy and sticky.
Doctor makes Dx : “pinkeye”.
Morgue workers turn into zombies  spawn a zombie epidemic
Culminates in characters dancing to “thriller” at the end

4. Case 23 m.o boy presented to PLC c/o L eye swelling, erythema & pain.
Doctor?

5. Hpi:
Hx of rhinorrhea, fever and conjunctival injection and R eye swelling 6 days ago.
Was rubbing eye. Saw FP 4 days ago who prescribed a topical ABx.
 R eye got better, but then L eye became swollen, red and tender

6. ROS: Fever 39.4 Mid-week. Hx finger poke to eye 1/12 ago. Nil else
PmHx: normal/healthy pregnancy. Normal vag delivery. No hospitalisations.
Immunisations: UTD

7. What will you look for?
Red Flags?

8. Physical Exam Vitals/general appearance: 37.2 , HR 110 , RR 24 , 98%
Flushed cheeks, but looks well
H&N:
L eyelid swollen and somewhat tender
No skin break/No proptosis/No
chemosis/ No conjunctivitis
Normal red reflexes/PEARL/ N eye mov’t

9. Physical Exam H&N cont’d: Normal TM’s/ Oropharynx clear/ No Lymph N’s
Rest of exam: N

10. Ddx? Infection Inflammation (blepharitis) Allergies Insect Bites
Periorbital / orbital
Conjunctivitis
herpes or varicella
Hordeolum
Chalazion
Dacrocystitis
Inflammation (blepharitis)
Allergies
Insect Bites
Trauma
Other: Tumors, Posterior scleritis , Periocular dermoid cyst ,Wegener's granulomatosis of the orbit, Orbital pseudotumor.

11. Anatomy: orbital septum Extends from the periosteum.
Fibrous sheath highly impermeable to infection.

12. Sinuses: Orbit shares a common wall with three sinuses: frontal sinus
ethmoid sinus
maxillary sinus.
Sinuses line 2/3 of the orbit.
Infections from contiguous spread.
ethmoid sinus is the usual culprit.
Why?
Has paper-thin wall [the lamina papyracea].

14. Classification Classically: Five categories I Preseptal cellulitis
II Orbital cellulitis
III Subperiosteal abscess
IV Orbital Abscess
V Cavernous Sinus thrombosis
What’s wrong with this?
Chandler JR et.al. The Pathogenesis of orbital complications in acute sinusitis. Laryngoscope 1970; 80:

15. Preorbital (preseptal) cellulitis:
More common than orbital cellulitis.
begins anteriorly  get spread to eye lids.
Etiology:
Conjunctivitis
Chalazion, hordeolum
Allergic reaction
Local infection/trauma eg insect bites, puncture wounds (cat bites e.g.)
Dacryocystitis
conditions such as erysipelas or impetigo.
 Rarely bacteremia

16. Chart Review of 108 cases in Sydney (preseptal  orbital abscess)
Lawless M and F Martin. ORBITAL CELLULITIS AND PRESEPTAL CELLULITIS IN CHILDHOOD. Australian and New Zealand Journal of Ophthalmology 1986; 14:
Chart Review of 108 cases in Sydney (preseptal  orbital abscess)
Cited predisposing factors as:
URTI (coryza, pharingitis, injected TM’s, nasal congestion)
Trauma (lacs, blunt injuries, animal bites/scratches)
Pimples, styes, chalazia
Dacrocystitis
other infections (herpes simplex/ varicella)

17. Preorbital (preseptal) cellulitis:
Clinically:
no significant fever
no leukocytosis
symptoms are localized to the lids and conjunctiva.
no pain on eye movement and vision is not impaired.
there is no evidence of sinusitis on plain film or CT.

18. Chalazia

19. Pre orbital cellulitis 20 to chalazion

20. Allergic reaction

21. Herpes blepharitis

22. Preorbital cellulits secondary to dacrocystitis

23. Preorbital (preseptal) cellulitis:
Treatment:
Oral antibiotics that cover skin flora.
amoxicillin-clavulanate
first-generation cephalosporin.
7-10 days (Uptodate)
Treatment failure in 24-48h warrants further w/u.
Etiology, Diagnosis, and Treatment of Orbital Infections
Gary Schwartz, MD Curr Infect Dis Rep Jun;4(3):

24. Orbital Cellulitis: Less common than preorbital
Pre antibiotic era mortality 20-50%
Mean age:
kids years
adults 30
Purported seasonality (winter months)

25. Orbital Cellulitis: Etiology:
60-90 % related to sinusitis (mostly Ethmoid)
Following URTI’s
Dental infections / surgery
erysipelas, impetigo, dacrocystitis
Trauma
More rarely bacteremia from endocarditis e.g

26. Clinical features: Classically: High fever Orbital pain
Limited extraoccular motion
Decreased vision
Proptosis
Increased WBC/ESR. Positive Blood Culture
Nelson Essentials of Pediatrics 4th Edition. Behrman RE and Kliegman RM. Eds Wb Saunders and Co. Pennsylvania USA

27. Retrospective review of 49 patients with dx orbital cellulitis.
Bergin DJ and Wright JE. Orbital Cellulitis. British Journal of Ophthalmology. 1986;
Retrospective review of 49 patients with dx orbital cellulitis.
Average age 30.
Symptom course 28 pts (57%) less than 7 days, 1-4 weeks in 17 (34%)
ALL had eyelid swelling
ALL had Chemosis
45 (91%) had reduced occular movement
46 (94%) had displaced eye (proptosis vs downward vs lateral displacement)

28. Clinical features cont’d:
Bergin DJ and Wright JE. Orbital Cellulitis. British Journal of Ophthalmology. 1986;
Only 16 (32%) had a fever.
23 (47%) had reduced visual acuity.
9 (27%) had an increased WBC
16 (32%) had ESR > 15 mm/h
30 (61%) had AbN sinus x-ray

29. Blood cultures only positive in 1 pt
Eustis ES. et al. Staging of orbital Cellulitis in Children: Computerised Tomography Characteristics and treatment Guidelines. Journal of Pediatric Ophthalmology and Strabismus. Sept/Oct 1986, Vol 23 No 5:
Retrospective review of 257 cases of periorbital and orbital (22) cellulitis at Sick Kids In Toronto
Orbital clinically:
 10 in Stage II (no decreased VA but 5 proptosis and 4 abn eye Mov’t, 3 had normal eye exam)
10 in Stage III ( 2 had decreased VA, 6 proptosis, 8 also had Abn eye mov’t)
1 in Stage IV (had abn VA, proptosis and Abn eye mov’t)
1 in Stage V
Sinusitis in 100%
Blood cultures only positive in 1 pt

30. Retrospective review of 12 cases in Cincinnati
Towbin, R et.al. Postseptal Cellulitis: CT in Diagnosis and Management. Radiology. 1986; 158:
Retrospective review of 12 cases in Cincinnati
9 (75%) had proptosis on admition. The other 3 developed it later.
11 (91%) had Abn eye movement
6 (50%) had painful eye mov’t
4 (33%) had diplopia
2 (16%) had decreased VA
2 (16%) had Chemosis

31. Retrospective Review 9 cases Mean age 9 8 had proptosis
Hirsch M and T Lifshitz. Computerised tomography in the diagnosis and treatment of orbital cellulitis. Pediatric Radiology. 1988; 18:
Retrospective Review 9 cases
Mean age 9
8 had proptosis
8 had partial/total opthalmoplegia or gaze defect
2 had decreased VA
2 positive cultures (staph)

32. Summary:
Early stages  pt may only present with swelling and induration confined lids
It is difficult to differentiate early orbital from periorbital cellulitis.
Absence of predisposing factor should raise your suspicion.

33. Summary cont’d: RED FLAGS: Tip: look for a “line of demarcation”
Proptosis / displaced eye
extraoccular muscle restriction
pain on eye movement,
chemosis
changes in visual acuity are
[NB: likely later signs].
Tip: look for a “line of demarcation”

37. If clinical exam not always reliable, What About imaging?
Plain Radiographs look for sinusitis:
Various Studies
radiography sensitivities % range (Spec also % range)
Bergin DJ and Wright JE. Orbital Cellulitis. British Journal of Ophthalmology. 1986;
“Sinus x-rays are an integral part of the evaluation of orbital disease”

39. Xray Summary
Can help in Dx, but not sensitive enough

40. What about U/S?
  Retrospective review 17 patients (aged 1 to 10 years; mean age 4.5 years
U/S performed either immediately or within 12 hr after admission.
Orbital cellulitis excluded in 9 pts
8 patients  orbital cellulitis diagnosed,
six had subperiosteal abscess
two had inflammation without abscess.
Conclude: “We recommend orbital sonography in every child with periorbital swelling and erythema”.
U/S Limitations  can’t image sinuses or calvarium
Mair MH; Geley T; Judmaier W; Gassner I Using orbital sonography to diagnose and monitor treatment of acute swelling of the eyelids in pediatric patients. Am J Roentgenol Dec;179(6):

41. CT: Who gets a CT? Came up with a protocol:
Towbin, R et.al. Postseptal Cellulitis: CT in Diagnosis and Management. Radiology. 1986; 158:
Came up with a protocol:
Kids with CNS manifestations / “Surgery Imminent” / Dx difficulty get scanned
Everyone else gets trial Abx for hours.
If the Abx fail to improve symptoms then the get scanned.

42. CT: Scan everybody so that one can stage the cellulitis
Hirsch M and T Lifshitz. Computerised tomography in the diagnosis and treatment of orbital cellulitis. Pediatric Radiology. 1988; 18:
Scan everybody so that one can stage the cellulitis
I -II can be treated conservatively
III and up go to the OR

43. CT: Most can be managed with Abx for 48h
Noel LP et.al. Clinical Management of Orbital Cellulitis in Children. Canadian Journal of Ophthalmology. 1990; 25 (1): 11-16
Most can be managed with Abx for 48h
Requires constant monitoring of patient
Failure of therapy buys a scan

44. CT: Most can be managed with aggressive Abx
Bergin DJ and Wright JE. Orbital Cellulitis. British Journal of Ophthalmology. 1986;
Most can be managed with aggressive Abx
Failure of therapy buys a scan (no comment on how long to trial abx)
Indications for surgery are failure to improve on Abx, presence of foreign body, subperiosteal (stage III), Orbital abscess (stage IV)

45. CT:
Eustis ES. et al. Staging of orbital Cellulitis in Children: Computerised Tomography Characteristics and treatment Guidelines. Journal of Pediatric Ophthalmology and Strabismus. Sept/Oct 1986, Vol 23 No 5:
CT for Visual Acuity decrease, proptosis, limitation of eye mov’t or uncertain of diagnosis
Failure of therapy buys a scan (no comment on how long to trial abx)
Indications for surgery are stage III (and presumably stage IV and V) . However “mild” stage III can be managed conservatively

46. CT Summary: Indications for CT scanning:
Inability to accurately assess vision
Gross proptosis, ophthalmoplegia, bilateral edema, or deteriorating visual acuity
No improvement despite 24 hours of intravenous antibiotics
Signs or symptoms of central nervous system involvement
Going to OR

49. Antibiotics: 3rd Gen Cephalosporin IV or Amoxilin/sulbactam
Suspected orbital cellulitis  admit the patient and begin aggressive Rx.
Empiric therapy should be directed against:
Gram Positives:
Streptococcus species: Streptococcus pneumoniae, Streptococcus viridans Staphylococcus aureus and epidermis
Gram Negs:
Moraxella catarrhalis (Haemophilus influenzae decreasing cause due to immunisations)
In adults: Also anaerobes  Bacteroides species  Veillonella parvula  Peptostreptococcus species  Fusobacterium species  
3rd Gen Cephalosporin IV or Amoxilin/sulbactam
Course should be IV until resolution but 14 d total
Sandford 2005

50. References:
Varonen H, Makela M, Savolainen S, Laara E, Hilden J, Comparison of ultrasound, radiography, and clinical examination in the diagnosis of acute maxillary sinusitis: a systematic review. Journal of Clinical Epidemiology, 2000, 53(9),
Ros SP. Herman BE. Azar-Kia B. Acute sinusitis in children: is the Water's view sufficient? Pediatric Radiology. 25(4):306-7, 1995.
Jain A and PA Rubin. Orbital Cellulitis in Children. Int Ophthalmol Clin Fall;41(4):71-86.

51. David G Hunter,Michele Trucksis
David G Hunter,Michele Trucksis. Preseptal (periorbital) and orbital cellulitis Uptodateonline.
Givner, Laurence B. M.D. Periorbital versus orbital cellulitis. Canadian Journal of Ophthalmology Feb;25(1):11-6.