Proptosis
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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.

References

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Dr Tom Leach

Dr Tom Leach MBChB DCH EMCert(ACEM) currently works as a GP Registrar and an Emergency Department CMO in Australia. He is also a Clinical Associate Lecturer at the Australian National University. After graduating from his medical degree at the University of Manchester in 2011, Tom completed his Foundation Training at Bolton Royal Hospital, before moving to Australia in 2013. He started almostadoctor whilst a third year medical student in 2009. Read full bio

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