Intern Report 8.5

Case Presentation by Xue Tian, MD

 

CC:  Left eye swelling, pain, and discharge

HPI:

A 26-year-old man presents to the ED complaining of a 6-day history of left eye pain, drainage, erythema and swelling of the eyelid. The patient says that he went to an urgent care 2 days ago and was prescribed ciprofloxacin eye drops. However, he has not seen an improvement in symptoms and states that the swelling is worse now. He also developed subjective fevers and chills at home today and he has pain with eye movement as well as decreased visual acuity.

ROS : Otherwise neg

PMHx:  None

PSHx:  None

Medications:  None

Allergies:  NKDA

FHx:  Heart disease

SHx:  Social drinker, smokes a pack a week x 10 years, denies other illicit drugs

 

Physical Exam: 

Vitals: BP 140/80        HR 80             RR 18              Temp 38.0      O2 99% RA

Gen – Lying in bed, eyes closed

Eyes – Chemosis of the L eye, scleral swelling, swelling and erythema of the eyelid, crusty. Visual acuity of L eye is 20/200, unable to count fingers. EOM restricted, significant pain with eye movement. Picture below.

 

 

Questons:

1. Which of the following is the most likely diagnosis?

A) Bacterial conjunctivitis

B) Pre-orbital cellulitis

C) Orbital cellulitis

D) Subconjunctival hemorrhage

 

2. What are the most pertinent questions to ask during history taking?

A) Pain with eye movement

B) Decreased visual acuity

C) Headaches

D) Fever

E) All of the above

 

3. Which of the following should be initiated for treatment?

A) IV ceftriaxone

B) IV ceftriaxone and vancomycin

C) Ciprofloxacin eye drops

D) IV antibiotics and surgical drainage

 

Answers:

1.C 2.E 3.B

1. C. Pre-orbital (or peri-orbital) cellulitis (B) must be differentiated from orbital cellulitis (C), since orbital cellulitis can lead to blindness. Pre-orbital cellulitis is an infection of the anterior eyelid, while orbital cellulitis involves structures inside the orbit. Pre-orbital cellulitis is less severe, whereas orbital cellulitis is associated with complications including orbital abscess, infection extending into the intracranial space, and Pott’s puffy tumor. Both of these diseases are more common in children. Bacterial conjunctivitis (A), also known as “pink eye,” is treated with erythromycin eye drops (or Cipro drops to cover Pseudomonas if the patient wears contact lenses or has any corneal abrasions). Subconjunctival hemorrhage (D) is usually due to spontaneous vessel rupture or trauma, and is usually flat and not associated with sclera edema.

2. E. The history and physical exam can help to differentiate pre-orbital from orbital cellulitis. Key findings of orbital cellulitis include fever, pain with eye movement, decreased visual acuity, headaches, proptosis, edema extending beyond the eyelid margin, and signs/symptoms of CNS involvement. In pre-orbital cellulitis you typically do not see proptosis or pain with extraocular eye movements. A Ct scan of the orbit and sinus can aid in differentiating between pre-orbital and orbital cellulitis.

3. B. The most common organisms seen in orbital cellulitis includes Staph spp., Strep spp., Bacteroides, and rarely Haemophilus influenza. Gram-negative bacteria are associated with post-traumatic orbital cellulitis. Mixed aerobes and anaerobes are associated with extension of a dental infection. Fungi, mucor, zygomycosis, and aspergillosis are associated with cases seen in immunocompromised individuals. Treatment includes IV vancomycin PLUS ceftriaxone, cefotaxime, unasyn, or zosyn. Cipro eye drops (C) are appropriate treatment for bacterial conjunctivitis. Surgical drainage (D) is not always necessary in orbital cellulitis.

References:

Block S. Getting an Eyeful of Preseptal Cellulitis. Pediatric Annals. 2013; 42: 99-102. doi: 10.3928/00904481-20130222-05 [link]

Nageswaran, Savithri (08/2006). “Orbital cellulitis in children”. The Pediatric infectious disease journal (0891-3668), 25 (8), p. 695.

Nickson C. The goggle-eyed fisherman. Life in the fast lane. 2010. [http://lifeinthefastlane.com/ophthalmology-befuddler-023/]

Quintana, E.C. Development of a clinical severity score for preseptal cellulitis in children

Annals of Emergency Medicine , Volume 44 , Issue 4 , 433

Thorner, A. Orbital cellulitis. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. Accessed on November 14, 2014.