Transcript 4.Orb cell & blowout fracture

Diseases of the orbit: orbital
cellulitis & blow out fracture
Dr. Ayesha S Abdullah
21.08.2015
Learning objectives
 ORBITAL CELLULITIS
By the end of the lecture the students should be
able to
1. 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 & signs
3. Describe the complications
4. 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 methicillinresistant 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 sinusesorbital 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 adnexadiseases 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