Proptosis

Original article by Anthony Rimmer | Last updated on 2/6/2014
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Orbital cellulitis

Ophthalmic emergency, infection of soft tissues behind orbital septum

  • extension of infection from periorbital structures (ethmoid sinusitis), face, globe, lacrimal sac or dental infection
  • direct inoculation of orbit from trauma
  • haematogenous spread from distant bacteraemia

Pathogens: Streptococcus pneumoniae, Staphylococcus aureus, Streptococcus pyogenes and Haemophilus influenzae
Unilateral, rapid onset of erythema and swelling, severe pain, blurred vision and diplopia
Systemic features: fever, headache, malaise.

Signs

  • lid erythema and oedema
  • reduced periorbital sensation
  • pain
  • reduced visual acuity
  • proptosis (laterally and downwards)
  • painful ophthalmoplegia and optic neuropathy

CT of sinuses, orbit and brain if intracranial abscess suspected
Staging:

  • Stage I: preseptal cellulitis
  • Stage II: orbital cellulitis
  • Stage III: subperiosteal abscess
  • Stage IV: orbital abscess
  • Stage V: cavernous sinus thrombosis and infection

Management

  • Preseptal cellulitis: oral co-amoxiclav for 10 days, drain lid abscesses
  • Orbital cellulitis: hospital admission under the ophthalmology and ENT
  • IM or IV antibiotics (ceftriaxone with flucloxacillin) and metronidazole (>10, chronic sino-nasal disease)
  • Optic nerve function: monitored every 4 hours
  • Treatment lasts 7-10 days
  • Surgery: CT evidence of orbital collection, no response, visual acuity decreases, atypical picture
  • Complications: exposure keratopathy, raised intraocular pressure, central retinal artery/vein occlusion, endophthalmitis, optic neuropathy, orbital abscess, meningitis, brain abscess and cavernous sinus thrombosis.