Preseptal and orbital cellulitis
- Lid lacerations
- Orbital trauma/fractures
- Thyroid eye disease
1. Preseptal and orbital cellulitis
Look for a source of entry for bacteria such as a local skin wound, sinusitis, insect bite, or a stye.
Look out for ocular movement restriction, pain, vision deterioration, or abnormal pupillary reactions. These may indicate an orbital extension which is sight-threatening.
Any open wounds should be swabbed and bloods may be sent including full blood count to check for leukocytosis and a CRP.
CT imaging of the head and orbits can be performed if orbital cellulitis, cavernous sinus thrombosis, or malignancy is suspected.
Note: The septum has not fully formed in children under the age of 10 years old and they are more likely to have retrobulbar spread and orbital cellulitis. Have a low threshold on children to image (MRI) if orbital cellulitis spread is suspected.
Mild cases can be treated with oral antibiotics (such as Coamoxiclav or Clindamycin if penicillin allergic).
Moderate to severe cases require intravenous antibiotics and admission to the hospital to be assessed by ophthalmology and ENT if a sinus source is suspected.
2. Lid lacerations
Establish if there is any damage or perforation to the globe or any foreign body potential.
Take a full history of the injury. Any laceration involving the lid margin itself should be referred to ophthalmology.
Assess the surface of the eye for any abrasions, foreign bodies, globe lacerations, or penetrations. Perform Seidel test (Figure 6-appendix 2)
Assess if the upper or lower canaliculus is involved, as this will affect the tear drainage system of the eye.
A dilated ocular examination is required at some point by an ophthalmologist.
If the lid margin is involved, the patient will need to see an ophthalmologist for a lid laceration repair, especially if the nasal upper or lower canthus is involved, as the nasolacrimal drainage system may be involved and will need to be assessed.
3. Orbital trauma/fractures
For the casualty doctor:
Check visual acuity, colour vision, pupils, and confrontational visual fields to rule out intraocular or optic nerve involvement.
Look for diplopia or pain on eye movements.
Subcutaneous or conjunctival emphysema may be present as well as hypoesthesia in the distribution of the infraorbital nerve (upper lip and ipsilateral cheek).
There may be enophthalmous, but this may be masked by periorbital swelling.
Document the height of hyphaema if present.
Offer analgesics e.g paracetamol PO and antiemetics e.g ondansetron 4-8mg IV
Place a Cartella shield over the eye (Figure 7-appendix 2) before referral to ophthalmology .
All wounds will require tetanus prophylaxis and broad spectrum antibiotic cover.
A CT scan is indicated if there is any head injury or potential foreign body in the orbit.
If severe, this condition may lead to preseptal or orbital cellulitis.
Treatment is with hot compresses six times a day and antibiotics e.g PO Coamoxiclav 625mg TDS (or Clindamycin PO 450mg QDS if penicillin allergic) and topical G. Chloramphenicol 0.5% QDS for 1-2 weeks.
Please refer to ophthalmology.
If features of orbital cellulitis are present, treat as described in orbital cellulitis section above.
5.Thyroid eye disease
This may present as proptosis, lid retraction, or strabismus.
If undiagnosed the patient’s GP may wish to undertake thyroid function and auto-antibody testing prior to referral and the patient may need referral to the endocrine team.
Please refer to the emergency clinic if there is sudden change in vision which is not attributable to simple dry eye as there could be a threat of optic nerve compression or exposure keratopathy.
Check visual acuity, pupils, Ishihara colour vision, and assess the corneal and optic nerve appearances
Manage with topical lubricants 4-8 times per day and a lubricating ointment at night-time if exposure keratopathy or any dryness is present.