OPHTHALMOLOGY

ResponseAtraumatic swollen red eye. ? fevers. ? recent URTI. Typically child

ResponseStreptococcus (pneumoniae/pyogenes)
Haemophilus
Staph. Aureus
Anaerobic bacteria in postseptal
(Sinus bacteria as sinusitis major cause here)

ResponseDirect innoculation from orbit (Trauma/surgery)
Extension from adjacent (periobital) Structures - Sinuses, face, globe, lacrimal sac
Haematogenous spread

(Same as osteomyelitis mechanisms)

ResponsePreseptal:
Normal VA
Mild upper lid erythema
Normal eye examination
No opthalmoplegia

Post-Septal:
Reduced VA/colour vision/diplopia. Gross proptosis
Opthalmoplegia
Reduced light reflex or swinging light test
Headache/vomiting, CNS signs/symptoms
Bilateral periorbital oedema (suggestive of cavernous sinus thrombosis)
Systemically unwell - drowsy, lethargy, fevers, irritable

ResponseFavour Orbital cellulitis (Over periorbital): Vision loss, Opthalmoplegia, pain on eye movement, proptosis, and conjuctival oedema

Detailed:
Proptosis - Subperiosteal or orbital abscess, orbital compartment syndrome
Opthalmoplegia/impaired mobility - occulur nerve/muscle compression, Cavernous sinus thrombosis
VA decreased, Field, RAPD - Optic nerve compression
Fundoscopy - optic nerve swelling - nerve compression/neuritis
IOP ?raised = sight threatening
Pain on eye movement - orbital cellulitis

Non ocular - sepsis/meningitis, other causes for fever etc.

ResponseFBC - WCC>20 suggests orbital cellulitis
Blood cultures
Swab MCS (+/- viral adeno HSV, VZV) - guide future antibiotics, does not effect immediate treatment
MRI/CT - Orbital imaging - Identifies complications - Abscess (Subperiosteal, orbital, cerebral), nerve compression, cavernous sinus thrombosis, OM, Identify underlying cause (sinusitis)

ResponseMild = cephalexin (33mg/kg TDS paeds)
Moderate = Admit for IVABx - Ceftriaxone 50 mg/kg BD OR fluclox 50 mg/kg QID
Severe treat as orbital (See below)
Penicillin hypersensitivity = Clindamycin (15 mg/kg)
Unvaccinated = Amoxiclav OR cefuroxime

ResponseSPECIFIC
IV antibiotics - broad spectrum + Staph cover

• Ceftriaxone 50 mg/kg BD (or cefotaxime)
• PLUS Fluclox 50 mg/kg QID

Surgical emergency - urgent ophthalmologic consultation ? decompression/abscess drainage

Generic
Analgesia, antipyretics
Discuss with parents
Admission - Ophthal + Paeds consultation

ResponseProgression to Orbital cellulitis/retroorbital cellulitis - pain on eye movement, ophthalmoplegia, loss of visual acuity, proptosis (note orbital = behind orbital septum, retro orbital = rear of eye)
Sinusitis
Visual Loss
Cavernous sinus thrombosis - headache, ptosis, CN III-VI palsy
Infection - orbital abscess, osteomyelitis, meningioencephalitis - Meningism, headache, confusion, ALOC
Bacteraemia - high grade fever, tachycardia, hypotension