There are frequently abscesses present BJO 14. Adults..trauma is involved, and in children sinusitis.
- Ceftriaxone: 1-2 g bd / IV infusion AND
*Metronidazole: 500 mg IV 8 hourly
- strep is often present
Orbital cellulitis in children
- Temp, pulse, resp rate, bp, mothers worry,
- swabs, ? Blood culture, fbc crp ue, lft,
- Anitbiotics, see child twice daily
- Same doctor each visit
- Well or unwell admit
- Eom, proptosis, check vision,iop, 90% sinus, (adults less sinus) most no abscess
- scan early, treat early,
- Antibiotics early iv, fluclox cefotaxime child and metronidazole
- Most common subperiosteal medial wall
- All abscesses drained urgently
- Medial ent, lateral orbital surgeon
- Differential..fungus, cst,etc
Preseptal cellulitis in children
- White eye, eom ok, scan admit, iv antibiotics, unwell, bloods,
- Oral 3d and not responding investigate, admit
- See response day 3
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.
||Signs and symptoms
|| Eyelid swelling, occasional fever
||If performed, sinusitis may be present
||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
||Signs of orbital cellulitis, systemic involvement, ophthalmoplegia, visual loss
||Orbital collection of pus with marked soft tissue changes of the fat and muscles
|| 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.
- Swabs nose, throat, conjunctiva,
- blood culture, FBC, CRP.
- Assess Visual acuity if possible.
- 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.
- Admission, IV ceftriaxone +/- ﬂucloxacillin and close observation in more severe preseptal or clearly orbital cellulitis, age under 2 years, immunocompromised or systemically unwell
- 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
- Add metronidazole if no improvement in 12-18 hours
- 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.)
- Urgent ENT opinion: surgical intervention may be indicated on ﬁrst CT scan, or by progressive pathology, which may require a repeat CT or MRI
- Consider ophthalmic examination (this may be impossible if lid oedema too tight for the globe to be visible)
- 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).
- 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
- BJO 15
- muscle and nerve enlargement
- lateral rectus enlarge
- Inferior rectus
- tendons enlarged
- middle age, male, any site
- Systemic health: pancreatitis, liver, bile duct, lymph node and orbital mass, salivary gland masses or fibrosis.
- It causes painless proptosis, responds a little to steroids, other salivary gland are affected,
- chronic inflammation noted on biopsy
- Previous biopsies may have missed the IG 4 findings: previously idiopathic, sometimes multi-organ, sometimes lymphoma in addition
- Raised ig 4 serum
- need to exclude ted and sarcoid with thyroid antibody and ACE test.
- Nerves involved, lacrimal gland, eg trigeminal nerve enlargement ...biopsy nerve
- also termed Anca vasculitis,
- local or systemic
- cough, haemoptysis, mastoiditis, sinus disease, deaf, nldo ( nasolacrimal duct obstruction with watery eye) renal failure, otitis media, proptosis, destructive inflammatory mass, scleritis, ulcerative keratitis, optic neuropathy
- bilateral, do well with treatment
- Ranlangans cell histocytosis or tutuons giant cells,
- 4 types
- Erdheim chester, necrobiotic, asthma, solitary
- Sometimes children
- Slowly progressive proptosis
- Retroperitonal fibrosis, heart
- Periocular skin, paraproteinaemia...myeloma, lymphoma, leukaemia
- Repeat biopsy
Lymphangioma of conjunctiva
- can present as chronic conjunctivitis, or as cellulitis or mass.
- Children may notice rapid changes.
- Breast, no history, men lung,
- Dacroadenitis, bacterial viral, inflammatory, history or injury...foreign body.
Adenoid cystic lacrimal gland
- female 40y
- eom reduced
- no inflammation
- Mass..excision biopsy and include track of biopsy to prevent seeding.
Orbit compartment syndrome due to retrobulbar haemorrhage
- local anaesthetic
- divide lateral canthal tendonhorizontal cut blunt scissors
- divide restricting bands of septum between lower lid and rim, then lid becomes mobile
Trapdoor orbital fracture
- dont blow nose
- dont eat/drink
- beware oculocardic reflex..upgaze causes bradycardia, nausea, vomiting, syncope, arrythmia, assystole
- refer urgent/ct scan
Optic nerve meningiomas
- optic nerve tumours may be primary or sedoncdary, but this description is about optic nerve meningiomas
- Apd mild proptosis, swelling of optic disc, collaterals
- Loss of sight x optic atrophy and shunts= meningioma
- Image patterns diffuse, fusiform, or like a secondary
- Tram tracking along optic nerve
- Primary treatment..radiation:
33% radiation retinopathy or neuropathy