Grand Rounds Conference Eric Downing MD University of Louisville Department of Ophthalmology and Visual Sciences

Subjective CC/HPI: Six year old male presented with fever, malaise, and progressive periorbital pain, proptosis, and decreased VA OD x 3 days CC/HPI: Six year old male presented with fever, malaise, and progressive periorbital pain, proptosis, and decreased VA OD x 3 days Presented to pediatrician's office 2 days prior to admission, diagnosed with sinusitis and was given oral Augmentin Presented to pediatrician's office 2 days prior to admission, diagnosed with sinusitis and was given oral Augmentin Symptoms progressed so mom took him to Floyd Memorial one day prior, where he was admitted for orbital cellulitis and placed on IV Ampicillin and Ceftriaxone. Symptoms progressed so mom took him to Floyd Memorial one day prior, where he was admitted for orbital cellulitis and placed on IV Ampicillin and Ceftriaxone. Pt and his mother complained of continued worsening symptoms despite IV antibiotics at time of exam Pt and his mother complained of continued worsening symptoms despite IV antibiotics at time of exam

History POH: none PMH: Recurrent nose bleeds Eye Meds: none Meds: PO Clindamycin x 1 day, IV Clindamycin and Ceftriaxone x 1 day IV Clindamycin and Ceftriaxone x 1 day

Objective OD OS OD OS VA: 20/100 20/20 Pupils: 6→4 6→4, no APD IOP:22 soft EOM:3+ restriction full in all fields of gaze

Objective Pen Light Exam OD: E/L/L: Severe periorbital edema with tight upper and lower lids, proptosis, 2mm lagophthalmos C/S:chemosis K: Clear, no staining AC: Formed I/L: WNL PLE OS: WNL

CT w/o Contrast

Assessment 6 year old male presented with fever, malaise, proptosis and blurry vision OD. Exam with only mildly increased IOP, but significant proptosis, lid tensity, significantly decreased EOM, ↓VA, and chemosis. 6 year old male presented with fever, malaise, proptosis and blurry vision OD. Exam with only mildly increased IOP, but significant proptosis, lid tensity, significantly decreased EOM, ↓VA, and chemosis. Dx: Orbital Cellulitis with secondary compartment syndrome Dx: Orbital Cellulitis with secondary compartment syndrome

Plan Lateral canthotomy/cantholysis Lateral canthotomy/cantholysis Consult Infectious Disease → recommended switch to Vancomycin and Zosyn Consult Infectious Disease → recommended switch to Vancomycin and Zosyn Consult ENT for possible sinus drainage Consult ENT for possible sinus drainage Re-evaluate IOP and motility in 4 hours and in AM Re-evaluate IOP and motility in 4 hours and in AM

Next morning… IOP 26 Worsening proptosis VA decreased to 20/800

MRI T1

MRI T2

Surgery Right orbital abscess drainage with external ethmoidectomy and penrose drain placement Right orbital abscess drainage with external ethmoidectomy and penrose drain placement Gram Stain: Gram positive cocci Gram Stain: Gram positive cocci Culture: MSSA Culture: MSSA

Post-op Received 9 additional days of IV antibiotics Received 9 additional days of IV antibiotics VA returned to 20/25 with significant improvement of motility VA returned to 20/25 with significant improvement of motility Discharged on PO Clindamycin Discharged on PO Clindamycin

Post-Op week 2 VA stable at 20/25 VA stable at 20/25 EOM full EOM full

Orbital Cellulitis Infection of the soft tissues of the orbit posterior to the orbital septum Infection of the soft tissues of the orbit posterior to the orbital septum Three etiologies Three etiologies Extension from periorbital structures, most commonly from the paranasal sinuses. Extension from periorbital structures, most commonly from the paranasal sinuses. Direct inoculation from trauma or surgery Direct inoculation from trauma or surgery Hematogenous spread from bacteremia Hematogenous spread from bacteremia

Background Prior to antibiotics, orbital cellulitis had a mortality rate of 17%, 20% were blind Prior to antibiotics, orbital cellulitis had a mortality rate of 17%, 20% were blind Mortality rate has decreased dramatically, but severe vision loss still occurs in 11% of patients Mortality rate has decreased dramatically, but severe vision loss still occurs in 11% of patients Corneal exposure, neurotrophic keratitis, intraocular tissue destruction, secondary glaucoma, optic neuritis, CRAO, orbital compartment syndrome Corneal exposure, neurotrophic keratitis, intraocular tissue destruction, secondary glaucoma, optic neuritis, CRAO, orbital compartment syndrome Orbital cellulitis due to S. aureus still presents a significant risk, even in spite of antibiotic therapy Orbital cellulitis due to S. aureus still presents a significant risk, even in spite of antibiotic therapy Complications Complications Meningitis (2%) Meningitis (2%) Intracranial abscess Intracranial abscess Cavernous sinus thrombosis—mortality rate of 50% Cavernous sinus thrombosis—mortality rate of 50%

Chandler Criteria 1. Preseptal 1. Preseptal 2. Diffuse edema w/o discrete abscess 2. Diffuse edema w/o discrete abscess 3. Subperiosteal abscess 3. Subperiosteal abscess 4. Orbital abscess with ophthalmoplegia and VA impairment 4. Orbital abscess with ophthalmoplegia and VA impairment 5. Extension into the cavernous sinus 5. Extension into the cavernous sinus

Chandler Criteria 1. Preseptal 1. Preseptal 2. Diffuse edema w/o discrete abscess 2. Diffuse edema w/o discrete abscess 3. Subperiosteal abscess 3. Subperiosteal abscess 4. Orbital abscess with ophthalmoplegia and VA impairment 4. Orbital abscess with ophthalmoplegia and VA impairment 5. Extension into the cavernous sinus 5. Extension into the cavernous sinus

Chandler Criteria 1. Preseptal 1. Preseptal 2. Diffuse edema w/o discrete abscess 2. Diffuse edema w/o discrete abscess 3. Subperiosteal abscess 3. Subperiosteal abscess 4. Orbital abscess with ophthalmoplegia and VA impairment 4. Orbital abscess with ophthalmoplegia and VA impairment 5. Extension into the cavernous sinus 5. Extension into the cavernous sinus

Chandler Criteria 1. Preseptal 1. Preseptal 2. Diffuse edema w/o discrete abscess 2. Diffuse edema w/o discrete abscess 3. Subperiosteal abscess 3. Subperiosteal abscess 4. Orbital abscess with ophthalmoplegia and VA impairment 4. Orbital abscess with ophthalmoplegia and VA impairment 5. Extension into the cavernous sinus 5. Extension into the cavernous sinus

Chandler Criteria 1. Preseptal 1. Preseptal 2. Diffuse edema w/o discrete abscess 2. Diffuse edema w/o discrete abscess 3. Subperiosteal abscess 3. Subperiosteal abscess 4. Orbital abscess with ophthalmoplegia and VA impairment 4. Orbital abscess with ophthalmoplegia and VA impairment 5. Extension into the cavernous sinus 5. Extension into the cavernous sinus

Epidemiology Median age is 7-12 years of age Median age is 7-12 years of age Incidence increases in winter due to increase in sinusitis Incidence increases in winter due to increase in sinusitis Children: 2:1 male/female predominance Children: 2:1 male/female predominance In adults, there is no gender difference, except S. aureus which is 4:1 female/male In adults, there is no gender difference, except S. aureus which is 4:1 female/male

History & Exam Fever, headache, malaise Fever, headache, malaise Blurry vision Blurry vision Recent history of sinusitis or upper respiratory tract infection Recent history of sinusitis or upper respiratory tract infection Recent trauma, surgery, or dental work Recent trauma, surgery, or dental work Proptosis Proptosis Ophthalmoplegia +/- pain Ophthalmoplegia +/- pain Chemosis Chemosis Decreased VA Decreased VA Elevated IOP (~22%) Elevated IOP (~22%) Resistance to retropulsion Resistance to retropulsion

Work-up Lab studies: Lab studies: CBC (WBC > 15K) CBC (WBC > 15K) Cultures: blood and/or any purulent material Cultures: blood and/or any purulent material Imaging Imaging CT with contrast CT with contrast MRI to define abscess and determine cavernous sinus disease MRI to define abscess and determine cavernous sinus disease Lumbar puncture if CNS or meningeal symptoms develop Lumbar puncture if CNS or meningeal symptoms develop

Treatment Prompt hospitalization with IV antibiotics Prompt hospitalization with IV antibiotics Canthotomy/cantholysis if orbital compartment syndrome is present Canthotomy/cantholysis if orbital compartment syndrome is present Surgical indications Surgical indications Decreased VA Decreased VA rAPD rAPD If proptosis or abscess progresses despite antibiotic therapy for hours If proptosis or abscess progresses despite antibiotic therapy for hours Fungal infections—debridement is often necessary, sometimes with exenteration of orbital and/or sinus tissues Fungal infections—debridement is often necessary, sometimes with exenteration of orbital and/or sinus tissues

Follow up At least daily monitoring with VA testing until significant improvement At least daily monitoring with VA testing until significant improvement May switch to oral antibiotics is patient is clearly improving AND has been afebrile for at least 48 hours May switch to oral antibiotics is patient is clearly improving AND has been afebrile for at least 48 hours IV therapy is often indicated for 1-2 weeks, followed by 2-3 weeks of oral antibiotics IV therapy is often indicated for 1-2 weeks, followed by 2-3 weeks of oral antibiotics

Research JAAPOS Vol 18:3, June 2014, Pages JAAPOS Vol 18:3, June 2014, Pages Retrospective review of 101 cases Retrospective review of 101 cases 71% of patients with abscess >3.8mL needed surgical intervention, only 12% if 3.8mL needed surgical intervention, only 12% if <3.8mL mL = ∏ x 4/3 x H x L x W mL = ∏ x 4/3 x H x L x W Suggested Chandler modification Suggested Chandler modification Stage 1: Preseptal cellulitis with no evidence of postseptal involvment Stage 1: Preseptal cellulitis with no evidence of postseptal involvment Stage 2: Signs of postseptal inflammation, such as orbital fat edema/stranding and/or scleral thickening Stage 2: Signs of postseptal inflammation, such as orbital fat edema/stranding and/or scleral thickening Stage 3: Phlegmon or subperiosteal abscess formation <3.8mL Stage 3: Phlegmon or subperiosteal abscess formation <3.8mL Stage 4: Abscess or phlegmon collection >3.8mL Stage 4: Abscess or phlegmon collection >3.8mL Stage 5: Extraorbital involvement Stage 5: Extraorbital involvement

References 1. BCSC: Pediatric Ophthalmology and Strabismus. Pp Bergin DJ, Wright JE. Orbital cellulitis. Br J Ophthalmol. Mar 1986;70(3) Hornblass A, Herschorn BJ, Stern K, et al. Orbital abscess. Surv Ophthalmol. Nov-Dec 1984;29(3):169-78