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 morgueaccidentally 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 epidemicCulminates 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
8 Physical Exam Vitals/general appearance: 37.2 , HR 110 , RR 24 , 98% Flushed cheeks, but looks wellH&N:L eyelid swollen and somewhat tenderNo skin break/No proptosis/Nochemosis/ No conjunctivitisNormal 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 / orbitalConjunctivitisherpes or varicellaHordeolumChalazionDacrocystitisInflammation (blepharitis)AllergiesInsect BitesTraumaOther: 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 sinusmaxillary 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 cellulitisIII Subperiosteal abscessIV Orbital AbscessV Cavernous Sinus thrombosisWhat’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:ConjunctivitisChalazion, hordeolumAllergic reactionLocal infection/trauma eg insect bites, puncture wounds (cat bites e.g.)Dacryocystitisconditions 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, chalaziaDacrocystitisother infections (herpes simplex/ varicella)
17 Preorbital (preseptal) cellulitis: Clinically:no significant feverno leukocytosissymptoms 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.
22 Preorbital cellulits secondary to dacrocystitis
23 Preorbital (preseptal) cellulitis: Treatment:Oral antibiotics that cover skin flora.amoxicillin-clavulanatefirst-generation cephalosporin.7-10 days (Uptodate)Treatment failure in 24-48h warrants further w/u.Etiology, Diagnosis, and Treatment of Orbital InfectionsGary 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 yearsadults 30Purported seasonality (winter months)
25 Orbital Cellulitis: Etiology: 60-90 % related to sinusitis (mostly Ethmoid)Following URTI’sDental infections / surgeryerysipelas, impetigo, dacrocystitisTraumaMore rarely bacteremia from endocarditis e.g
26 Clinical features: Classically: High fever Orbital pain Limited extraoccular motionDecreased visionProptosisIncreased WBC/ESR. Positive Blood CultureNelson 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 swellingALL had Chemosis45 (91%) had reduced occular movement46 (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 WBC16 (32%) had ESR > 15 mm/h30 (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 TorontoOrbital 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 VSinusitis 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 Cincinnati9 (75%) had proptosis on admition. The other 3 developed it later.11 (91%) had Abn eye movement6 (50%) had painful eye mov’t4 (33%) had diplopia2 (16%) had decreased VA2 (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 casesMean age 98 had proptosis8 had partial/total opthalmoplegia or gaze defect2 had decreased VA2 positive cultures (staph)
32 Summary:Early stages pt may only present with swelling and induration confined lidsIt 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 eyeextraoccular muscle restrictionpain on eye movement,chemosischanges 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 Studiesradiography 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 SummaryCan 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 yearsU/S performed either immediately or within 12 hr after admission.Orbital cellulitis excluded in 9 pts8 patients orbital cellulitis diagnosed,six had subperiosteal abscesstwo 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 calvariumMair 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 scannedEveryone 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 cellulitisI -II can be treated conservativelyIII 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): 11-16Most can be managed with Abx for 48hRequires constant monitoring of patientFailure 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 AbxFailure 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 diagnosisFailure 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 visionGross proptosis, ophthalmoplegia, bilateral edema, or deteriorating visual acuityNo improvement despite 24 hours of intravenous antibioticsSigns or symptoms of central nervous system involvementGoing 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 epidermisGram 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/sulbactamCourse should be IV until resolution but 14 d totalSandford 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.