Ординатура / Офтальмология / Английские материалы / Oculoplasty and Reconstructive Surgery Made Easy_Garg,Touky, Nasralla_2009
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Preseptal Cellulitis and Orbital Cellulitis 389
Older children can be managed as out patient using oral broad spectrum antibiotics. Broad spectrum or newer cephalosporins can be administered.
Surgical treatment is hardly required. About 10% of the children will require surgical drainage of the lid abscess or para nasal sinus.
Complication1,3
1.CNS Infection like meningitis, epidural abscess, subdural empyema and brain abscess.
2.Orbital involvement leading to orbital cellulitis or orbital abscess.
3.Cavernous sinus thrombosis.
4.Toxic shock syndrome.
5.Eschar formation leading to scarring.
Prognosis
With appropriate and prompt treatment the prognosis is good.
ORBITAL CELLULITIS
Orbital cellulitis is an uncommon but important entity which can give rise to serious systemic and ocular complication.
Orbital cellulitis is an infection of the soft tissue of the orbit posterior to the orbital septum. Proper and prompt diagnosis and management is very important for treating the patients with orbital cellulitis.
Pathophysiology
Orbital cellulitis occurs in following three conditions:1,2,4
1.Extension of infection from periorbital structures mainly paranasal sinuses and from face, globe and lacrimal sac.
2.Direct inoculation from trauma and surgery.
3.Hematogenous spread from bacteremia.
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Medial orbital wall is thin and is perforated by numerous blood vessels and nerves and also by other defects like Zuckerkandl dehiscence.
This defect in walls allows for easy communication of infectious material between ethmoidal air cells and subperiosteal space in the medial aspect of the orbit leading to formation of subperiosteal abscess.
Posterior in the orbit, the fascia between rectus muscles is thin and incomplete allowing easy extension between extraconal and intraconal orbital space.
Infectious material can also be introduced in the orbit directly from accidental or surgical trauma.
Ethmoidal sinusitis is the most common cause of orbital cellulitis and aerobic non-spore forming bacteria is the most frequently responsible organism.
Clinical Features
Important significant sign is presence of proptosis and ophthalmoplegia (Figure 2).
Other signs are:
• Conjunctival chemosis
Figure 2: Orbital cellulitis (Courtesy: Anthony Moore: Paediatric Ophthalmology, David Taylor)
Preseptal Cellulitis and Orbital Cellulitis 391
•Decreased vision
•Increased intraocular pressure
•Pain on eye movement.
It can also be accompanied with lid edema, rhinorrhea and increasing malaise.
Causes1,2,4
•It is commonly seen secondary to ethmoidal sinusitis mainly in children more than 5 years old in almost 90% cases.
•Bacterial infection like type B Hemophillus influenzae,
Staphylococcus aureus, Streptococcus pyogenes, Strep. pneumoniae and anaerobes like Bacteroides species.
•Penetrating orbital trauma mainly incases of retained foreign body.
•Secondary to surgical procedures including orbital decompression, DCR, eyelid surgery, strabismus surgery, retinal surgery, etc.
•Fungi: Most common organisms are Mucor and Aspergillus.
Aspergillus gives rise to chronic proptosis and decreased visual acuity.
Mucor mycosis can lead to orbital apex syndrome.
Complication1,4
1.Ocular: includes exposure keratopathy, raised intracranial pressure, CRAO/CRVO, endophthalmitis, optic neuropathy.
2.Intracranial: Meningitis, brain abscess and cavernous sinus thrombosis. Cavernous sinus thrombosis is important complication and should be suspected in cases of bilateral orbital cellulitis, rapidly involving proptosis and presence of congestion of facial, conjunctival and retinal veins.
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3.Subperiosteal abscess: It is located along the medial orbital wall. It is seriously entity having potential progression plus intra cranial extension.
Diagnosis:1,4
•Complete blood count: Leucocytosis with count more than 15,000 with shift to left is seen in most of the cases.
•Blood cultures prior to administration of antibiotics.
•Grams stain to identify the type of organism.
•Needle aspiration from the orbit is contraindicated.
•X-ray paranasal sinus for diagnosis of ethmoidal sinusitis.
•Dental examination to rule out any dental infection.
•High resolution CT scan is very diagnostic modality to conform the diagnosis and extent of the disease. It is used in detecting subperiosteal and orbital abscess which can be missed in normal X-ray.
•MRI is helpful in defining the orbital abscess and evaluation of cavernous sinus disease.
•Orbital ultrasound can also detect orbital abscess but is less reliable.
•Lumbar puncture is indicated in patients with meningeal signs to rule out meningitis
Treatment4
1.Hospital admission: Opinion from the pediatrician and ENT surgeon is important before starting with the management.
2.Administration of broad spectrum antibiotics: Ceftazidime 1 gm is given IM 8 hourly and metronidazole in dose of
500 mg every 8 hourly.
Alternative IV vancomycin can also be used. Antibiotic treatment is continued until the patient is apyrexial for 4 days.
Optic nerve function is monitored every 4 hourly for pupillary reaction, visual acuity, color vision.
Preseptal Cellulitis and Orbital Cellulitis 393
Surgery is usually indicated:4
•Unresponsive to antibiotics
•Decreasing visual acuity
•Orbital/subperiosteal abscess. It is important to drain the infected sinuses as well as the orbits.
REFERENCES
1.Anthony Moore – Paediatric Ophthalmology, 13, 107-13. Preseptal and Orbital Cellulitis.
2.E- medicine Orbital Cellulitis
3.E-medicine Preseptal Cellulitis
4.Jack J Kanski – Clinical ophthalmology – Orbital Infections.17;56770.
5.Londer L, Nelson DL. Orbital cellulitis due to Hemophillus influenza Arch Ophthalmology 1974;91:89-98.
6.Schranm VL, Myers EN. Orbital complication of Acute Sinusitis Otolaryngol 1978;86:221-30.
7.Wallers E, Wallers H, Hiles D. Acute Orbital Cellulitis, Arch ophthalmology 1976;94:785-8.
8.Goldberg F, Berne AS. Differentiation of Orbital Cellulitis from Preseptal cellulitis by Computed Tomography Paediatrics 1978:62:1000-9.
9.Barkins RM, Todd JK. Periorbital cellulitis in children. Paediatrics. 1978: 62:390-2.
10.Smith TF, O’Day et al. Clinical implications of preseptal cellulitis in childhood.
CARBUNCLE
Introduction
Acute suppurative inflammation of multiple meibomian glands along with the blockage of their ducts, results in eyelid abscess or carbuncle.
Clinical Features
•Intense pain
•Maximum tenderness can be elicited at a number of points on the swelling
•Swelling is usually away from the eyelid margin
•Multiple pus points are usually seen on the cutaneous surface (Figures 1 and 2).
Differential Diagnosis
•Hordeolum externum
•Hordeolum internum
•Molluscum contagiosum
•Malignancy, etc.
Treatment
• Hot compresses are useful in the cellulitis stage.
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Figures 1 and 2: Carbuncle upper eyelid
•Systemic antibiotics and anti inflammatory medicines are advised.
•Pus is evacuated in the later stages through a transcutaneous incision parallel to the lid margin.
Prognosis
• Good, if managed in time.
CARUNCULAR ABSCESS
Introduction
The caruncle consists of a mass of fibrous tissue similar to that of the tarsal cartilages, in which are imbedded follicles secreting a fluid similar in nature to that of the meibomian glands. This fluid comes out through twelve to fifteen excretory orifices on its surface, which is covered by the conjunctiva.
The healthy caruncle is yellowish-red in color, slightly tuberculated on the surface, which, in addition to the excretory orifices, is beset with very delicate scarcely visible hair.
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Figures 3 and 4: Caruncular abscess
The caruncular abscess is similar to that of the meibomian glands (Figures 3 and 4).
Clinical Features
Similar to catarrhal inflammation of the caruncle and semilunar fold, but as suppuration takes place
•Pain becomes throbbing in nature, and
•Redness and swelling of the surrounding tissues increases, until
•It presents as a yellow point between the caruncle and the semi-lunar fold, which
•Bursts out, resulting in the evacuation of the abscess and
•Finally atrophy of the caruncle (Figures 3 and 4).
Differential Diagnosis
•Caruncular growth
•FB embedded in the caruncle.
Treatment
•Oral broad spectrum antibiotics, along with
•Topical broad spectrum antibiotics in the form of eye drops or an eye ointment.
•Warm fomentation is applied on the medial canthus when suppuration is threatened.
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•The abscess is opened with a sharp disposable needle or a lancet, once fluctuation is elicited or the yellow point presents.
Prognosis
•Good with medical treatment and surgical evacuation, if necessary.
CONCRETIONS (LITHIASIS)
Introduction
Concretions are yellowish white, hard, raised pin head sized lesions on palpebral conjunctiva. These are formed by accumulation of dead epithelial cell debris and inspissated mucous into the depressions called Henle’s glands. They never become calcareous so the term concretion is a misnomer. The concretions get their name from the fact that these are hard and pointed and can scratch the cornea.
Clinical Features (Figure 5)
•Foreign body sensation
•Lacrimation, and
•Recurrent corneal abrasions.
Figure 5: Concretions (Lithiasis)
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Differential Diagnosis
•Concretions may occur in the elderly, or in
•Chronic inflammatory conditions like:
•Vernal conjunctivitis,
•Atopic keratoconjunctivitis,
•Post-trachomatous degeneration, etc.
Treatment
Concretions are removed with a 26 G hypodermic needle after anaesthetizing the conjunctival sac.
Prognosis
Prognosis following removal is good, but recurrences do occur.
ECTROPION OF LOWER PUNCTA
Introduction
•Lacrimal puncta are small round or oval openings of the lacrimal canaliculi, approximately 0.3 mm in diameter and are situated at the edge of the medial end of each eyelid, in line with the openings of the meibomian glands.
•Upper punctum is situated 6 mm temporal to the inner canthus, while the lower punctum is 6.5 mm away.
•Each punctum is positioned astride a slight elevation called the lacrimal papilla, and is not visible in health, as it faces the bulbar conjunctiva, and dips into the pool of the tears, which collects in the inner canthus and is called Lacus lacrimalis (Figures 6 and 7).
Clinical Features
•Chief complaint of the patient is excessive watering from the eyes.