The Goggle-eyed Fisherman

Orbital/ post-septal cellulitis

Features present in the image include:

• eyelid edema and erythema
• chemosis and an engorged conjunctiva
• proptosis

History:

• Symptoms — red eye, pain, blurred vision, double vision, eyelid swelling, nasal congestion, sinus headache/ pressure, tooth pain, periorbital pain or hypesthesia.
• Consider possible underlying causes — trauma, surgery, ENT or systemic infection, diabetes mellitus, and immunosuppression

Examination:

• Visual acuity: may be reduced in severe cases due to optic nerve stretch or compression
• External exam:
  eyelids: eyelid edema, erythema, warmth, tenderness
  conjunctiva: chemosis and injection
  proptosis
  other: purulent discharge and decreased periorbital sensation may be present
• Extraocular eye movements: restricted ocular motility with pain on attempted eye movement.
• Pupils: RAPD may be present in severe cases due to optic nerve stretch or compression
• Fundoscopy: retinal venous congestion and optic disc edema in severe cases.
• General exam: Fever; and in severe and progressive disease altered mental state and meningism may occur. Look for evidence of an underlying cause or predisposition (see Q2).

• Adults: Staphylococcus species, Streptococcus species, Bacteroides
• Children — Staphylococcus species, Streptococcus species, Haemophilus influenzae (rarely in vaccinated children)
• Post-traumatic: Gram-negative bacteria
• Dental abscess: mixed, aggressive aerobes and anaerobes
• Immunocompromised or diabetes mellitus: consider fungi, e.g. mucormycosis/zygomycosis, aspergillosis.

• Laboratory: FBC, blood cultures, wound swabs, consider the need for lumbar puncture.
• CT scan of the orbits and sinuses: confirms the diagnosis and helps to exclude cavernous sinus thrombosis, orbital or subperiosteal abscesses, paranasal sinus disease and foreign bodies

Referral to ophthalmology for admission to hospital. An infectious diseases consult is often appropriate

Consider consultant the following:

• neurology — if suspected CNS infection
• ENT — if drainage of the sinuses is needed
• oral/maxillofacial surgeons — if emergency dental extraction is needed

Based on the Australian Therapeutic Guidelines, at least 3 days of:

• cefotaxime 2 g (child: 50 mg/kg up to 2 g) IV 8-hourly
• or ceftriaxone 2 g (child: 50 mg/kg up to 2 g) IV daily
• AND flucloxacillin 2 g (child: 50 mg/kg up to 2 g) IV, 6-hourly.

Followed by:

• amoxycillin+clavulanate 875+125 mg (child: 22.5+3.2 mg/kg up to 875+125 mg) orally, 12-hourly to complete a total of 14 days antibiotics.

Further anaerobic cover may be required (e.g. metronidazole), for instance, if a dental cause is suspected. If MRSA is suspected consult an infectious disease specialist and consider treatment with vancomycin.

Other treatments may be required:

• analgesia
• Nasal decongestant spray as needed for up to 3 days.
• Erythromycin ointment qid — for corneal exposure and chemosis if there is severe proptosis.
• canthotomy/cantholysis — may be required if the orbit is tight, optic neuropathy is present or the IOP is severely elevated.
• abscess drainage

Periorbital/ pre-septal cellulitis

Periorbital (or preseptal) cellulitis is a soft-tissue infection of the eyelids that does not extend past the orbital septum posteriorly. It causes eyelid and periorbital edema, redness, and discomfort.

The ocular exam should be essentially normal:

• normal visual acuity
• FROEM without significant discomfort
• absence of proptosis

Sometimes the clinical distinction is unclear and imaging is necessary (e.g. CT orbits and sinuses).

Much the same as for orbital cellulitis:

• Staphylococcus aureus
• Streptococcus pneumoniae
• Streptococcus anginosus/milleri group
• Haemophilus influenzae type b (Hib) in the unvaccinated

Systemically well children <5 years of age:

• amoxycillin+clavulanate 22.5+3.2 mg/kg po q12h for 7 days
• OR cephalexin 12.5 mg/kg orally, 6-hourly for 7 days

Older children or adults or children with an infected wound or stye, etc:

• flucloxacillin 500 mg (child: 12.5 mg/kg up to 500 mg) orally, 6-hourly for 7 days – (cephalexin and clindamycin are options in the setting of penicillin hypersensitivity)

If systemically unwell it is best to treat and investigate for orbital cellulitis.

• Ehlers JP, Shah CP, Fenton GL, Hoskins EN. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease Lippincott Williams & Wilkins
• NSW Statewide Opthalmology Service. Eye Emergency Manual — An illustrated Guide. [Free PDF]