The Goggle-eyed Fisherman

aka Ophthalmology Befuddler 023

A 38 year-old professional fisherman presents to your emergency department after returning to shore from a 3 week trip. Over the past week he has had progressively worsening left eye symptoms and is now feeling quite unwell.

He has been having fevers, has a constant headache and his left eye has become swollen. He reports a history of double vision but now he has trouble seeing anything out of his left eye. Any movement of the eye causes significant pain.

His eye looks like this:

orbital-cellulitis
Photo by bobjgalindo (click on image for source)

Questions

Q1. What is the likely diagnosis?
Answer and interpretation

Orbital/ post-septal cellulitis

Features present in the image include:

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

Q2. What features should be assessed when taking the history?
Answer and interpretation

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

Q3. What  features should be looked for on examination?
Answer and interpretation

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).

Q4. What causative organisms are usually responsible for this condition in the different settings in which it can occur?
Answer and interpretation
  • Adults: Staphylococcus species, Streptococcus species, Bacteroides
  • ChildrenStaphylococcus 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.

Q5. What investigations are required when considering this diagnosis?
Answer and interpretation
  • 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

Q6. What is the appropriate management?
Answer and interpretation

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


Your next patient is a small child who is systemically well. He has developed redness and swelling around his right eye over the past few days:

periorbital cellultis

Q7. What is the likely diagnosis?
Answer and interpretation

Periorbital/ pre-septal cellulitis


Q8. What are the clinical features of this condition, and how is it distinguished from the goggle-eyed fisherman’s diagnosis?
Answer and interpretation

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).


Q9. What organisms cause this condition in children <5 years of age?
Answer and interpretation

Much the same as for orbital cellulitis:

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

Q10. What is the antibiotic treatment of this condition?
Answer and interpretation

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.


References

Ophthalmology Befuddler 700

CLINICAL CASES

Ophthalmology Befuddler

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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