Diseases of the orbit: orbital cellulitis & blow out fracture Dr. Ayesha S Abdullah 21.08.2015

Diseases of the orbit: orbital cellulitis & blow out fracture

Dr. Ayesha S Abdullah21.08.2015

Learning objectives ORBITAL CELLULITISBy the end of the lecture the students

should be able to1.Differentiate between preseptal and true

orbital cellulitis 2.Explain why it is considered to be an

ocular emergency 3.Describe the causes, 4.Explain the clinical presentation,

complications & line of management of orbital cellulitis

BLOW-OUT FRACTURE (BOF) OF THE ORBIT

By the end of the lecture the students should be able to

1.Explain the mechanism of BOF of the orbit

2.Describe its symptoms & signs3.Describe the complications4.Outline the management

Orbital cellulitis

• Preseptal cellulitis • True orbital cellulitis

Preseptal orbital cellulitis

• Infection of the subcutaneouss tissue anterior to the orbital septum ( lids)

• Causes: – Trauma; lid laceration/ insect bite– Spread from local infection; stye/

dacrocystitis– Spread from remote infection;

haemotogenous spread from middle ear/ Upper Respiratory Tract

• Clinical presentation – Symptoms; History of predisposing factor,

pain & swelling of the lid, mild fever– Signs; red swollen tender lids sometimes

the lids may be difficult to open. Important negative signs are:• Eye itself is normal at the most might be

mildly congested• Visual acuity is normal• No proptosis• No ocular motility problem• Normal pupils

•Complications –True orbital cellulitis–Lid abscess–Cavernous sinus thrombosis

Management

• Symptomatic; analgesics & NSAIDS• Specific:• Very severe infections may require Adults:

250 – 500 mg oral Co-amoxiclav qds/ tds depending on severity of infection.

• Children: 20-40mg/kg/day oral co-amoxiclav over 24h in three divided doses.

• benzylpenicillin 2.4-4.8 mg I/M 6 hourly in severe infections

• Lid abscesses should be drained• Third generation cephalosporins in penicillin

allergy

Orbital cellulitis

• Infection of the soft tissues behind the orbital septum ( deeper to lids)

• Ocular emergency , could be life threatening

• Most frequent pathogens are; Strept. Pneumoniae , staph aureus, strept. Pyogenes & H influenzae - (under 5 yrs children)

Causes

• Spread from the sinuses; mostly ethmoidal in children & young adults

• Extension from preseptal cellulitis• Local spread; dacrocystitis, dental

infection, facial infection, infection of the eyeball ( panophthalmitis etc)

• Haemotogenous spread• Post- traumatic; accidental/ surgical

Clinical presentation

• Symptoms; rapid onset painful swelling of the lids & protrusion of the eye, fever, malaise & visual loss ; history of risk factors

• Signs; moderate to severe swelling of the lids, reduced visual acuity, proptosis,red eye with chemosis of the conjunctiva, abnormal & painful EOM & pupillary response

Complications

Ocular; corneal damage( exposure),raised IOP, vascular occlusions, optic nerve damage, endophthalmitis

Intracranial; meningitis, brain abscess, cavernous sinus thrombosis

Orbital abscess

Management

• Symptomatic; antipyretic, NSAIDS• Specific ; hospitalization & antibiotic therapy

– Ceftazidime 1 g tds , I/M– Mteronidazole 500mg tds, PO – Vancomycin in case of allergy to the above

mentioned

• Surgical intervention in case of local abscess or unresponsive cases

• Consultation with ENT specialist, neurosurgeon & paediatrician if required

Case #1

A 1 year old child presented to the OPD of department of ophthalmology with the complaint of a swollen right upper lid for the last two days. On examination the lid was red, warm & tender to touch. His visual acuity was normal, the eye had mild conjunctival redness, the pupil was normal and the ocular movements were also normal. Watch the photograph….

Some questions

1. Is the condition confined to the lids or has it involved the eyeball?

2. Why do you think so?3. What more information would you like

to have before making a diagnosis?

Some more information………

• The child had a history of insect bite on the lid two days ago, the swelling increased thereafter. The insect bite mark was visible

• There was no history of trauma or symptoms suggestive of sinusitis

• His temperature was 990 F

Some more questions

• What should be the management, keeping in mind the nature of the problem?

• Is there any role of health education in this case?

Let us see an other case……..

Case #2• A seven year old child was brought the OPD of

the department of ophthalmology with a history of swollen left upper lid for the last 5 days. He also had fever for the last two days. On examination the child had a grossly swollen lid. The doctor had difficulty in opening the lid for examination of the eye. The visual acuity was 6/6 OD & 6/18 OS. The lid was warm and tender. The eye was moderately proptosed with conjunctival chemosis. The pupil was slow to react to light and the ocular movements were painful & limited. The temperature was 1010 F & the child looked generally unwell……..

Some questions….

1. Is the condition confined to the lids or has it involved inner orbit?

2. What more information should we ask for to get an idea about the cause of the problem?

• The child had a history of recurrent flu and upper respiratory tract infections. He had history of blocked nose and thick greenish nasal discharge was noted on examination.

• The child was put on intravenous antibiotics but didn’t get better

• Why?

The antibiotics were changed to intravenous ampicillin/sulbactam and after 5 days were changed to oral amoxicillin/clavulanic acid for a total of 14 days of

antibiotics.

Some more questions

• What should be the management, keeping in mind the nature of the problem?

• What do you think can be done with the abscess?

• Is there any role of health education in this case?

..

Conclusion about the two cases

• What is the difference between the two cases?

• We consider the second case an ocular emergency, why?

• Why did the subperiosteal abscess form in the second case?

• What other complications could happen in the second case?

Let us summarize

• Preseptal orbital cellulitis & orbital cellulitis are both infections.

• It is more common in children• The route of infection could be from the

nearby infectious focus like infected sinuses, skin wound or spread of infection via blood

• The most common cause especially in children is ethmoidal sinusitis

•

• Both preseptal and orbital cellulitis may have: – Fever – Eyelid swelling– Pain – Red eye – Child is ill-appearing

• Orbital cellulitis signifies spread of inflammation to the posterior orbital contents that is the eyeball, extraocular muscles: helpful signs to distinguish it are:-– Proptosis – Decreased visual acuity ( may be normal in the

beginning)– Red eye with conjunctival chemosis of

moderate to intense congestion– Painful limited eye movements – Afferent pupillary defect

• Prior to the availability of antibiotics, patients with orbital cellulitis had a mortality rate of 17%, and 20% of survivors were blind in the affected eye. However, with prompt diagnosis and appropriate use of antibiotics, this rate has been reduced significantly

• blindness can still occur in up to 11% of cases. Orbital cellulitis due to methicillin-resistant Staphylococcus aureus can lead to blindness despite antibiotic treatment.

• Mortality/Morbidity:

BLOW-OUT FRACTURE OF THE ORBIT

• Secondary to massive blow to the orbit resulting in fracture of one/ more of its walls ( mostly medial wall & floor)

• Common in sports & violence related trauma

• Mechanism involves sudden rise of intraorbital pressure & fracture of the bony socket at its weakest points

Clinical presentation

• Symptoms ; history of trauma with double vision, pain in and around the orbit, visual loss ( not always)

• Signs; periocular swelling, bruising ( ecchymosis), subcutaneous emphysema

• Enophthlamos; in large & severe fractures & increases with time

• Infraorbital nerve hypo/ anesthesia

Clinical presentation • EOM abnormalities; vertical diplopia,

limited upgaze & downgaze --- floor fractures, limited adduction & abduction ---medial wall fracture

• Ocular/ associated damage to the eyeball– Hyphaema– RD– Damage to the angle of the anterior

chamber—glaucoma– Vitreous haemorrhage– Orbital hematoma– Damage to the optic nerve

Complications

• EOM problems• Visual loss• Cosmetic • Secondary infection from the

sinuses- orbital cellulitis & spread of the infected contents of the sinuses to the vital tissues like the eyeball & the brain

Investigations/ confirmatory tests

For confirmation of fracture • CT scan / X ray orbit For confirmation of muscle

entrapment• CT scan & forced duction test

Management

• Symptomatic/ conservative: NSAID for relief of pain & reduction of inflammation ( discourage blowing of the nose to prevent forcing of the infected sinus contents into the orbit), antibiotics

• If the diplopia persist beyond 2 weeks/ enophthamos is significant then surgical repair of the fracture with release of entrapped muscles may be required

Summary

• Orbital cellulitis is a potentially vision threatening & life threatening disorder more commonly seen in children & young adults, requires hospitalization & intensive in-patient treatment

• Blowout fracture is not a common disorder but is common in sports & violence related trauma, it can mostly be managed conservatively but in case of a large fracture or persistent EOM problems & enophthalmos may require surgical repair.

References

• Orbit, eyelids & lacrimal system. American Academy of Ophthalmology; 1997-98

• Jack J Kanski. Clinical ophthalmology a systematic approach. 5th ed;2003:567-69, 661-665

• Parsons’ diseases of the eye. Diseases of the adnexa-diseases of the orbit. 19th ed. 2004; 505-524

• Newell F W. The orbit. In Ophthalmology principles & concepts.7th ed; 1992:259-69

• Web resources : http://www.emedicine.com/OPH/topic205.htm

• http://www.patient.co.uk/showdoc/40025295