Orbital Infection To Orbit Inflammation

Front 1

Chandler's clasification for infections involving orbit and adnexa

Back 1

Preseptal

• stage 1- preseptal cellulitis
  
• stage 2- orbital cellulitis
  

Retroseptal

• stage III subperiosteal abscess
  
• stage IV Orbital abscess
  
• Stage V Cavernous Sinus Thrombosis
  

Front 2

What is Preseptal Cellulitis?

Back 2

its an infection of the soft tissue of the eyelids, anterior to the orbital septum.

the globe and orbit are NOT involved

Front 3

Preseptal cellulitis could arise from:

Back 3

spread of infection from:

1. eyelid injuries
   
2. insect or animal bites
   
3. conjunctivitis
   
4. hordeolum
   
5. sinusitis
   
6. a upper respiratory or middle ear infection
   

Front 4

Most common bacterias to cause Preseptal Cellulitis are:

Back 4

Staphylococcus Aureus

Streptococcus Pyogenes

Streptococcus Pneumoniae

in Children

H. Influenza (causes red purplish coloration)

human or animal bite: anaerobic bacteria like

Peptostreptococcus and Bacteroides

Front 5

Preseptal cellulitis signs:

Back 5

Unilateral lid erythema, edema

WARMTH, tenderness

NO PROPTOSIS or EOM restriction

VA NOT AFFECTED neither are PUPILS

CT Scan: opacification anterior to orbital septum

Front 6

Preseptal Cellulitis Symptoms

Back 6

Mild fever

redness

lid tenderness

irritablity in children

Front 7

Differential Diagnosis for Preseptal Cellulitis

Back 7

Orbital Cellulitis-proptosis, pain of EOM, decreased VA, fever, chemosis

Proptosis

Acute Hordeolum- will have palpable mass

Allergic eyelid swelling- will itch, no tenderness

Conjunctivitis

Cavernous Sinus Thrombosis

Erysipelas

Front 8

MILD Preseptal cellulitis Tx : ORAL ANTIBIOTICS

Back 8

children older than 5 -

Amoxicillin/clavulanate (augmentin) or

Ceclor (Cefaclor) 20-40mg/kg/day in 3 doses for 10 d (max 1g/day)

Adults

augmentin 250-500mg q8h or 800mg bid 7-10d

or

ceclor same dose q8h for 10d

Front 9

My pt has MILD preseptal cellulitis and is allergic to penicillin what do i give him?!!

Back 9

Bactrin (trimethoprim/sulfamethoxazole)

8mg/kg/day thrimethoprim/ 40mg/kg/day sulfamethoxazole po in 2 doses

adults 160mg/800mg po bid for 10 d

Front 10

MILD Preseptal cellulitis pt is allergic to penicillin and sulfa....what do i give him?

Back 10

Erythromycin

children 30-50mg/kg/day in 3-4 doses

adults 250-500mg q 6h for 10d

Front 11

if etyology for preseptal cellulitis is bite wound then the antibiotic would be:

Back 11

penicillin G IV

ampicillin/sulbactam

cefoxitin

all cover anaerobs

Front 12

for moderate-severe preseptal cellulitis tx is

• refer for admision to hospital for
• IV antibiotics
• which are?

Back 12

Ceftriaxone

children 100mg/kg/day iv in 2 doses

adults 1-2g iv q12h

and

Vancomycin

children 40mg/kg/day iv 3-4 doses

adults 0.5-1g iv q 12h

change iv antibiotics to oral once there is improvement.

Front 13

Preseptal cellulitis tx in adittion to Antibiotics is;

Back 13

warm compresses tid

polysporin ung qid if theres conjunctivitis

follow up daily until improvement,

then q 2-7 d

Front 14

What is Orbital Cellulitis

Back 14

a life threatening infection that affects the soft tissues behind the orbital septum.

Most common routes of infection are:

1. adjacent sinuses or teeth
   
2. direct inoculation throu penetrating lid injury.
   

Front 15

Common infectious agents of Orbital cellulitis are:

Back 15

if infection is from local trauma:

s. aureus

s. pyogenes

if from sinus infection:

streptococcus pneumoniae

in diabetic or immunosuppresed patients:

fungi

Front 16

Orbital cellulitis is most often caused by:

Back 16

extention of infection in the ethmoid sinus

Front 17

A serious complication of orbital cellulitis is:

Back 17

if the infection spreads thru a valveless venous system and leads to

1. cavernous sinus thrombosis
   
2. meningitis
   
3. intracraneal infection
   
4. septicema causing death
   

Front 18

Symptoms of orbital cellulitis are:

Back 18

pain

reduced vision

redness

diplopia

fever

malaise- se siente mal, malestar

Front 19

Signs of Orbital Cellulitis:

Back 19

prominent lid edema

redness

distention

proptosis

significant pain upon palpation

diplopia

Vision loss and APD

Front 20

Orbital cellulitis managemetn:

Back 20

TRUE EMERGENCY REFER TO HOSPITAL FOR IV ANTIBIOTICS.

IV Antibiotics for G+, G- AND anaerobics for 1 week

Front 21

IV Antibiotics used for CHILDREN with Orbital Cellulitis?

Back 21

Vancomycin 40mg/kg/day 2-3 divided doses

or

Nafcillin 150mg/kg/day in 6 doses

PLUS

Ceftriaxone 100mg/kg/day in 2 doses

Front 22

IV Antibiotics used for Adults with Orbital Cellulitis?

Back 22

Ceftriazone 1-2g q12h

or

Nafcillin 1-2g q4h

PLUS

Vancomycin 1g q 12h

Front 23

Adult is suspected to have Chronic Orbital cellulitis or to be infected by anaerobes.

what antibiotic should you add?

Back 23

Metronidazole 15mg/kg for IV load

then

7.5mg/kg IV q 6h

Front 24

if orbital cellulitis pt is allergic to PCN/Cephalosporin use:

Back 24

Vancomycin 1g IV q12h

or

Clindamycin 300mg IV q 6h

PLUS

Gentamycin 2.0mg/kg IV loading dose, then 1mg/kg IV q 8h

Front 25

Orbital Cellulitis follow up:

Back 25

1. Monitor Optic nerve function
   
2. ENT consultation for sinus drainage
   
3. if there's exposure keratopathy use Erythromycin ung qid
   
4. surgery to decompress orbit, drain abscess, open infected sinuses or combination if infection doesnt resolve with antibiotics, vision is compromised, fb suspected, imaging shows abcess.
   
5. follow up everyday in hospital 24-36 hr to show improvement

Front 26

What is Mucormycosis

Back 26

1. Fungal infection of the orbit from Mucoraceae.
   
2. Diabetic and immunocompromised pts are vulnerable.
   
3. agressive and potentially fatal
   
4. happens when you inhale spores
   

Front 27

Signs of Mucormycosis:

Back 27

1. Proptosis
   
2. necrotic mucosa on the nose and palate
   
3. black eschar
   
4. gradual onset of facial and periorbital swelling, diplopia and visual loss.
   
5. opthalmoplegia has a slower progression compared to orbital cellulitis
6. quite ill, pain

Front 28

Complications of mucormycosis

Back 28

1. Retinal vascular occlusion
   
2. multiple Cranial nerve palsies
   
3. cerebrovascular occlusion
   

IF its not treated may result in:

1. Meningitis
   
2. brain abcess
   
3. death
   

recurrences are common

Front 29

Treatment of Mucormycosis is:

Back 29

hospitalize

IV Amphotericin B - CHOICE!!!!

0.25-0.30mg/kg IV over 3-6 hrs the 1st day.

0.5mg/kg IV the 2nd day. then 45-50 mg IV daily

• Watch for renal compromise
  
• daily packing and irrigation
  
• adjunctive hyperbaric oxygen
  
• exenterating in severe unresponsive cases
  
• excision of necrotic tissues

Front 30

What is Idiopathic Orbital Inflammatory Disease (IOID)

Back 30

• an uncommon but frequent cause of proptosis in adults (20-50) and children.
  
• of idiopathic etiology
  
• produces inflammation that is diffuse and may involve any or all of the orbital soft tissues. which results in: myositis, dacryoadenitis, optic perineuritis or scleritis

Front 31

IOID is characterized by:

Back 31

Non neoplastic

non infectious

space occupying orbital lesions

histologically it shows pleomorphic cellular inflammatory infiltration followed by fibrosis.

in adults its unilateral, in children can be bilateral

Front 32

IOID is sometimes associated with:

Back 32

systemic vasculitis such as:

polyarteritis nodosa- affects medium vessels

lymphoma

wegener's granulomatosis

Front 33

Symptoms of IOID are:

Back 33

1. rapid onset with pain
   
2. prominent redness
   
3. diplopia
   
4. decreased va
   
5. can be acute, recurrent or chronic
   
6. children might have fever too
   

Front 34

Signs of IOID are:

Back 34

proptosis

and/or restriction of EOM unilaterally (usually)

CT shows :

• thickened posterior sclera, orbital fat,
  
• lacrimal gland involvement
  
• EOM thickening.
  

Front 35

IOID may also include (signs):

Back 35

1. might raise IOP
   
2. hyperopic shift
   
3. ON swelling or atrophy
   
4. decreased sensitivity of 1st division of CN V
   
5. conjunctival chemosis
   
6. injection
   

Front 36

IOID workup is:

Back 36

1. case hx, opthalmological evaluation
   
2. ESR
   
3. CBS with differential
   
4. ANA
   
5. BUN
   
6. Creatinine to rule out vasculitis
   
7. FBS to rule out mucormycosis
   
8. ANCA test if wegener's granulomatosis is suspected.

Front 37

Treatment for IOID :

Back 37

Prednisolone 80-100mg po qd

and

anti ulcer med: Ranitidine 150mg po bid

Low radiation if theres no response to steroids

Front 38

Follow up for IOID is:

Back 38

1. re evaluate in 3-5 days
   
2. if tx worked maintain initial dose for 1-2 weeks, then taper slowly for several months (monitor IOP)
3. if no response to steroids order a biopsy
   

Front 39

This disease is a diagnosis of exclusion

Back 39

Tolosa Hunt Syndrome (THS)

Front 40

What is Tolosa Hunt Syndrome?

Back 40

non specific inflammation within

the cavernous sinus or

superior orbital fissure

that causes acute constant orbital pain

mnemonic: tolosa hunts in the cavernous sinus entering thru the superior orbital fissure

Front 41

Tolosa hunt syndrome causes:

Back 41

Opthalmoparesis due to palsies of

CN III, IV and VI

Pupillary disfunction related to injury to CN III

may have Forehead paresthesia due to trigeminal nerve involvement (V1)

its uncommon in pts older than 20 yrs.

may affect optic nerve if it goes beyond sinus but its rare

Front 42

Symptoms of Tolosa hunt syndrome

Back 42

1. Painful opthalmoparesis or Opthalmoplegia
   
2. double vision
   
3. eyelid droop bc of III palsy
   
4. facial pain or numbness
   

Front 43

Signs of Tolosa Hunt syndrome

Back 43

pain can precede opthalmoplegia

optic, trigeminal (V1-corneal reflex lost) and ocular nerves affected

III and VI are the most commonly affected

Ptosis bc of III palsy

Mild proptosis, or optic disc edema if orbit involved

inflammatory involvement produces:

horner syndrome with myosis

Front 44

What does unilateral III palsy and Horner's syndrome indicate?

Back 44

an inflammation at the cavernous sinus.

Front 45

to Diagnose Tolosa Hunt syndrome you must rule out these first:

Back 45

1. AV fistula
   
2. cavernous sinus thrombosis
   
3. metastatic tumors to cavernous sinus
   
4. pituitary apoplexy
   
5. intracavernous aneurysm
   
6. mucormycosis
   
7. herpes zoster
   
8. meningioma
   
9. spenoid carcinoma
   
10. mucocele
    
11. infections
    

Front 46

Tests to diagnose Tolosa Hunt Syndrome

Back 46

• MRI to cavernous sinus
  
• orbital venography and fine needle biopsy to cavernous sinus
  

Front 47

Rare multisystem autoimmune disease of unknown etiology

with the hallmark features of:

• necrotizing granulomatous inflammation
  
• pauci-immune vasculitis in small and medium sized blood vessels
  

Back 47

Wegener's Granulomatosis

Front 48

Wegener's Granulomatosis is characterized by:

Back 48

1. Small vessel vasculitis affecting mainly respiratory tract and kidneys
   
2. subtle onset, CAN BE LETHAL
   
3. can be localized in the eye and orbit only with no systemic involvement.
   
4. happens more in males

Front 49

Wegener's signs of orbital involvement are:

Back 49

1. Proptosis, Orbital congestion, opthalmoplegia
   
2. Dacryoadenitis and nasolacrimal duct obstruction
   

other ocular involvement like:

• necrotizing scleritis
  
• peripheral ulcerative keratitis
  
• occlusive retinal periarterirtis
  
• and rarely tarsal conjuctival disease
  

Front 50

test to diagnose Wegener's Granulomatosis is:

Back 50

cANCA test- anti-neutrophilic cytoplasmic antibody test which is found in 90% of pts with the disease.

Front 51

treatment for webener's granulomatosis is:

Back 51

Cyclophosphamide- immunosuppresor

steroids

in resistant cases use:

cyclosporine, azathioprine, antithymocyte globulin or plasmapheresis

surgical: orbital decompression

Front 52

Pt comes in with acute discomfort in the lacrimal gland area, these are symptoms of:

Back 52

Acute inflammatory dacryoadenitis

Front 53

Signs of Acute inflammatory dacryoadenitis are:

Back 53

1. unilateral swelling in eyelid- s shaped ptosis
   
2. tenderness over lacrimal gland fossa
   
3. injection at lacrimal gland palpebral and adjacent conjunctiva
   
4. reduced lacrimal secretion can happen
   
5. Pt does NOT have fever-bc its not an infection

Front 54

Differential Diagnosis for acute inflammatory dacryoadenitis:

Back 54

lacrimal gland infection

ruptured dermoid cyst

malignant lacrimal gland tumor

improves with steroids and not antibiotics

Front 55

Inflammation of one or more of the EOM with no known etyology is called:

Back 55

Orbital Myositis

histologically will present:

chronic inflammatory cellular infiltrate in the muscle fibers

Front 56

Symptoms of Orbital Myositis are:

Back 56

1. acute pain in early adults made worse with EOM movement
   
2. Diplopia
   

Front 57

Signs of Orbital Myositis:

Back 57

1. Lide edema, ptosis, chemosis, diplopia
   
2. pain on attempted gaze
   
3. vascular injection over muscle
   
4. mild proptosis
   
5. if chronic may become permanent restrictive myopathy
   

ct Scan will show fusiform enlargement of muscles with or without tendons involved.

Front 58

Differential Diagnosis for Orbital Myositis:

Back 58

1. Thyroid Opthalmopathy- but this one is painless on onset, slowly progressive and asoc. w/ graves
   
2. Acute non recurrent cases may resolve in 6 weeks
   
3. Chronic is a single episode that lasts more than 2 months or recurrent attacks.
   

Front 59

Treatment for Orbital Myositis:

Back 59

NSAID for mild cases

Systemic Steroids-great but reocurrences can happen

Radiotherapy- good to limit reocurrences