Good Hope, Heartlands, and Solihull Eye Clinics

Orbit notes       

David Kinshuck 2015

 

Orbital cellulitis

There are frequently abscesses present BJO 14.  Adults..trauma is involved, and in children sinusitis.

Adults Protocol.

Children

Orbital cellulitis in children 

Preseptal cellulitis in children 

Preseptal and Orbital cellulitis in Children (Tina Kipioti 2017)

Infective orbital cellulitis and its complications can be classified into five types which are not mutually exclusive and do not necessarily progress in that order.

 

Stage Signs and symptoms CT findings
Preseptal cellulitis Eyelid swelling, occasional fever If performed, sinusitis may be present
Orbital cellulitis Proptosis, decreased painful eye movements, chemosis Sinusitis, mild soft tissue changes in the orbit
Subperiosteal abscess Signs of orbital cellulitis, systemic involvement Subperiosteal abscess, globe displacement, soft tissue changes in the orbit
Orbital abscess Signs of orbital cellulitis, systemic involvement, ophthalmoplegia, visual loss Orbital collection of pus with marked soft tissue changes of the fat and muscles
Intracranial complication Signs of orbital or rarely preseptal cellulitis, marked proptosis, cranial nerve palsies (III, IV, V, VI) Intracranial changes: cavernous sinus thrombosis, extradural abscess, meningitis, and osteomyelitis


It can be difficult to differentiate between preseptal and orbital cellulitis and the diagnosis may change from preseptal to orbital. Clinical diagnosis and management is based on above signs, general appearance of the child and the severity of lid swelling, which may prevent an adequate examination of the globe.

The most common organisms are Strep pyogenes, Strep pneumoniae, and Staph aureus (most common over 5 years). Hib (haemophylus) is now uncommon since vaccination had started. Anaerobes are uncommon.

Management

  1. Swabs nose, throat, conjunctiva,
  2. blood culture, FBC, CRP.
  3. Assess Visual acuity if possible.
  4. Children with mild to moderate preseptal cellulitis can be managed in the same way as uncomplicated sinusitis on an outpatient basis with oral Co-amoxiclav for 10 days. Add topical Chloramphenicol drops qds for 5-7 days if red eye or purulent discharge.
  5. Admission, IV ceftriaxone +/- flucloxacillin and close observation in more severe preseptal or clearly orbital cellulitis, age under 2 years, immunocompromised or systemically unwell
  6. Continue IV antibiotics until joint agreement that there is significant resolution (minimum 48 hours), then home on oral Co-amoxiclav to complete 10 days

If no improvement or progression in 12-18 hours

  1. Add metronidazole if no improvement in 12-18 hours
  2. Urgent CT scan to assess orbital, sinus & brain involvement, when lid swelling prevents an adequate examination of the globe, no improvement of preseptal or clear signs of orbital cellulitis. (MRI preferred if available.)
  3. Urgent ENT opinion: surgical intervention may be indicated on first CT scan, or by progressive pathology, which may require a repeat CT or MRI
  4. Consider ophthalmic examination (this may be impossible if lid oedema too tight for the globe to be visible)
  5. Surgical drainage of abscess is an ENT decision (recommended if orbital abscess, failure to improve after 48h despite treatment or deterioration, signs of severe complications- consider NeuroSx opinion).
  6. Continue IV antibiotics until joint decision for home and until afebrile for 48 hours. Then oral Co-amoxiclav for 7-14 days 11. Follow up may include paediatricians, ophthalmologists, ENT especially if drainage of abscess.

Invasive fungal disease of the sinus and orbit

Ig 4 disease

Wegners

Xanthogranulomas

Lymphangioma of conjunctiva

Lymphoma

Rabdomyosarcoma

Secondaries

Dacroadenitis

Adenoid cystic lacrimal gland

Biopsy

Orbit compartment syndrome due to retrobulbar haemorrhage

Fractures

Optic nerve meningiomas

Some notes

 
Case 68y

Case2