Orbital Cellulitis
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Orbital cellulitis is an infection of the soft tissues of the orbit posterior to the orbital septum. It may be a continuum of preseptal cellulitis, which is an infection of the soft tissue of the eyelids and periocular region anterior to the orbital septum. Orbital cellulitis may result from an extension of an infection from the paranasal sinuses or other periorbital structures such as the face, globe, or lacrimal sac, direct inoculation of the orbit from trauma or surgery or as a haematogenous spread from bacteremia.
Clinical presentation
- Fever, malaise, and a history of recent sinusitis or upper respiratory tract infection
- Proptosis and ophthalmoplegia are the cardinal signs of orbital cellulitis
- Conjunctival chemosis, dyschromatopsia, and relative afferent pupillary defect
- Decreased vision
- Elevated intraocular pressure
- Pain on eye movement
- Orbital pain and tenderness are present early
- Swollen eyelids, chemosis, hyperemia of the conjunctiva, and resistance to retropulsion of the globe may be present
- Purulent nasal discharge may be present
- For very ill children, vision may be difficult to evaluate in very ill children with marked edema
Investigations
- Visual acuity
- Slit lamp bimicroscopy
- Tonometry
- Fundoscopy
- Full Blood Count and ESR
- Blood culture
- Assessment of purulent nasal discharge or from the abscess (swab for Gram Stain)
- CT Scan of the orbits and paranasal sinuses with Contrast
- MRI will help differentiating it with other diseases but also identifying the source or extension of the disease
Non-pharmacological Treatment
- Patients must be hospitalized
- Adequate hydration
- Lower the temperature
- Daily evaluation and monitor the vital signs
- Management of orbital cellulitis is done with consultation from other medical team (Neurosurgical (if brain extension is seen), ENT (for involvement of sinuses), Paediatrician (for paediatric patients) and Physicians
Pharmacological Treatment
The antibiotic will be tailored when the laboratory results are out.
Adults, give:
B: ampicillin + cloxacillin (FDC) (IV) 1g stat then 500mg 6hourly for 2weeks
AND
A: gentamicin (IV) 160mg 24hourly for 7days
AND
B: metronidazole (IV) 500mg 8hourly for 7days
AND
S: vancomycin (IV) 15–20 mg/kg 8–12hourly
Children more than one-month old give:
B: ampicillin + cloxacillin (FDC) (IV) 50 mg /kg 8hourly for 7–14days
AND
A: gentamicin (IV) 7.5mg/kg, 24hourly for 5 -7days
AND
B: metronidazole (IV) 7.5–15mg/kg 6hourly for 7–10days
AND
S: vancomycin (IV) 10mg/kg 6hourly for 7–10days
Note: Individual dose not to exceed 1g Children less or equal to one-month old give:
B: ampicillin + cloxacillin (FDC) (IV) 25–50mg/kg 8hourly for 7–14days
AND
A: gentamicin (IV) 5mg/kg 24hourly for 5–7days
Steroidal anti–inflammatory medicines To be given after 48 hours of antibiotic therapy. Give:
A: prednisolone (PO) 1–2mg/kg 24hourly to be tapered slowly
AND
Adults:
A: ibuprofen (PO) 400–800mg 6–8hourly; not to exceed 3.2g 24hourly
OR
A: paracetamol (PO) 1g 4–6hourly to a maximum of 4 doses 24hourly, for 3days
Children:
A: ibuprofen (PO) 30–40mg/kg per day in 3–4doses
OR
A: paracetamol 10–14 mg/kg for 3days
Note: Do not use ibuprofen in patients with bleeding disorders or peptic ulcers
Surgical TreatmentSurgical drainage is only indicated when there is:
- A decrease in vision
- Development of an afferent pupillary defect
- Progression of Proptosis despite appropriate antibiotic therapy
- The size of the abscess does not reduce on CT scan within 48–72hours after appropriate antibiotics have been administered
- If brain abscesses develop and do not respond to antibiotic therapy, then craniotomy is indicated
- Presence of a drainable fluid collection is evident on CT scan in patients older than 16years