MORNING REPORT
Gaby Paskin
7/2/13
JM
5 year old female comes to the ER with pain and
swelling of left eye for 1 day
 Punched in the eye by her 3 year old brother
yesterday
 Yesterday developed photophobia, and mom
patched her eye
 This morning, increased swelling, pain, unable to
open eye, so came to ED

JM CONTINUED
No fevers, no LOC, no dizziness, no
nausea/vomiting, no discharge from eye
 +mildly blurred vision
 Refusing to open left eye
 In ED, febrile to 102.7
 On exam: significant swelling of upper and lower
eyelid, + tenderness to palpation, mild ptosis,
+decreased lateral movement of eye

JM CONTINUED
WBC: 32.1
 Hg/Hct: 14.7/40.8
 Plt: 441
 CT: mildly depressed fracture of left lamina
papyracea with adjacent sinus opacification and
inflitration of intraorbital fat

DDX
Orbital cellulitis
 Preseptal cellulitis
 Trauma
 Bites
 Allergic reaction
 Hordeolum
 Conjunctivitis
 Mucocele
 Graves disease
 Tumor

ORBITAL/PRE-ORBITAL CELLUITIS
Orbital cellulitis: infection involving the content
of the orbit (fat and ocular muscles)
 Preorbital/preseptal cellulitis: infection of
anterior portion of eyelid
 Neither involves infection of the globe

PRESEPTAL CELLULITIS
Infections of the soft tissues anterior to the
orbital septum
 Rarely leads to serious complications
 More common in children than adults
 Causes: often external sources, not sinuses

Local trauma: bites
 Foreign bodies
 Staph aureus, strep pneumo, other streps, anaerobes,
MRSA

PRESEPTAL CELLULITIS CONTINUED

Clinical manifestations
Ocular pain
 Eyelid swelling
 Erythema
 Rarely chemosis in severe cases


Diagnosis
History and physical
 Imaging


CT orbit/sinuses
TREATMENT
Children > 1 year and mild preseptal cellulitis, no
systemic toxicity: treat as outpatient
 < 1 year, cannot cooperate for full exam, or
severely ill: admit and manage according to
orbital cellulitis recommendations
 PO antibiotics: Clindamycin or Bactrim + amox,
Augmentin, Cefpdoxime, cefdinir, 7-10 days
 Fail to show improvement in 24 hours should be
hospitalized for IV antibiotics

ORBITAL CELLULITIS
Infections posterior to the orbital septum
 More common in young children than older
children and adults
 Rhinosinusitis is most common cause of orbital
cellulitis

Uncommon complication
 Usually from ethmoid sinusitis or parasinusitis
 Other causes: ophthtalmic surgery, ocular trauma,
dacryocystitis, infection of teeth, face or middle ear

ORBITAL CELLULITIS CONTINUED

Micro



Usually Staph and strep
Rarely can be fungi or mycobacteria
Clinical manifestations








Ocular pain
Eyelid swelling
Erythema
Pain with eye movements
Proptosis
Ophthalmoplegia
Chemosis
Visual impairment (inflammation or ischemia of optic
nerve)
COMPLICATIONS

Subperiosteal abscess
15-59% of cases
 Sometimes requires surgery


Orbital abscess
Up to 24%
 More severe symptoms


Vision loss
3-11%
 Secondary to optic neuritis, ischemia, increased pressure




Cavernous sinus thrombophlebitis
Central retinal artery occlusion
Brain abscess
DIAGNOSIS

Exam

Ophthalmoplegia, pain with eye movement,
proptosis, chemosis
Consult ophtho
 Imaging




CT or MRI
MRV if concern for thrombosis
Indication to image: proptosis, limitations of eye
movement, pain with eye movement, diplopia, vision
loss, edema extending beyond eyelid margin, ANC >
10,000, signs or symptoms of CNS involvement,
inability to examine the patient fully (<1 yo), patients
who do not begin to show improvement with in 24-48
hours of initiating appropriate therapy
TREATMENT

Broad spectrum antibiotics: to cover S. aureus,
strep and gram-negative bacilli
Vanco and ceftriaxone, cefotaxime, Unasyn or Zosyn
 If suspected intracranial extension, also cover for
anaerobes (metronidazole)

Should show improvement within 24-48 hours
 Oral medications when afebrile and findings
have started to resolve
 Surgery if unresponsive, large abscess, worsening
vision changes

QUESTION 1


A.
B.
C.
D.
E.
A 4 year old boy presents with a 40day histpry of
worsening right eyelid swelling and redness aftera
mosquito bite. On physical exam, his temperature is 38.0,
HR 100, RR 25. His right eyelid is markedly swollen, red
and tender, andhe is unable to open it fully. His
conjunctivae are clear, and extraocular movements are not
limited. There is no proptosis. Visual acuity is difficult to
assess fully but appears normal. There are no other
physical findings or note. The WBC is 19 with 55% PMN,
20% bands, 20% lymphocytes, and 5% monocyte.
Of the following, the MOST appropriate antibiotic for this
patient is
Ampicillin-sulbactam
Cefazolin
Clindamycin
Doxycycline
Trimethoprim-sulfamethoxazole
QUESTION 2


A.
B.
C.
D.
E.
A 14 year old softball player comes to the emergency
department after being struck in the eye by a pitch. She is
awake, and alert, complaining of right eye and face pain.
She has obvious swelling and ecchymosis around her right
orbit. Her extraocular movements are normal on the left,
but she is unable to look up with her right eye. Her globe is
intact, vision is 20/20 in both eyes and pupils are equally
round and reactive; no corneal injuries are apparent on
fluoresecin examination.
Of the following, the injury that BEST explains this girl’s
physical findings is
Epidural hematomoa
Intracranial contusion
LeFort fracture, type 1
Right orbital floor fracture
Right temporal skull fracture
QUESTION 3
A 2 year old boy presents to your office with a 2-day
history of swelling of the right eye. He has been
otherwise well. There are scattered insect bites on his
body, including one about 2 cm lateral to the affected
eye. There is no discharge, and the bite appears to be
healing. The boy’s right eyelids are swollen and seem
tender to palpation.
 Of the following, the MOST concerning additional
ophthalmologic finding for this boy is
A.
Decreased extraocular movements
B.
Hyperemia of the palpebral conjuctiva
C.
Photophobia
D.
Purulent exudates
E.
Subconjunctival hemorrahges
