1. Diseases of the orbit: orbital cellulitis & blow out fracture
Dr. Ayesha S Abdullah

2. Learning objectives ORBITAL CELLULITIS
By the end of the lecture the students should be able to
Differentiate between preseptal and true orbital cellulitis
Explain why it is considered to be an ocular emergency
Describe the causes,
Explain the clinical presentation, complications & line of management of orbital cellulitis

3. BLOW-OUT FRACTURE (BOF) OF THE ORBIT
By the end of the lecture the students should be able to
Explain the mechanism of BOF of the orbit
Describe its symptoms & signs
Describe the complications
Outline the management

4. Orbital cellulitis
Preseptal cellulitis
True orbital cellulitis

5. Preseptal orbital cellulitis
Infection of the subcutaneouss tissue anterior to the orbital septum ( lids)
Causes:
Trauma; lid laceration/ insect bite
Spread from local infection; stye/ dacrocystitis
Spread from remote infection; haemotogenous spread from middle ear/ Upper Respiratory Tract

6. Clinical presentation
Symptoms; History of predisposing factor, pain & swelling of the lid, mild fever
Signs; red swollen tender lids sometimes the lids may be difficult to open. Important negative signs are:
Eye itself is normal at the most might be mildly congested
Visual acuity is normal
No proptosis
No ocular motility problem
Normal pupils

7. Complications True orbital cellulitis Lid abscess
Cavernous sinus thrombosis

8. Management Symptomatic; analgesics & NSAIDS Specific:
Very severe infections may require Adults: 250 – 500 mg oral Co-amoxiclav qds/ tds depending on severity of infection.
Children: 20-40mg/kg/day oral co-amoxiclav over 24h in three divided doses.
benzylpenicillin mg I/M 6 hourly in severe infections
Lid abscesses should be drained
Third generation cephalosporins in penicillin allergy

9. Orbital cellulitis
Infection of the soft tissues behind the orbital septum ( deeper to lids)
Ocular emergency , could be life threatening
Most frequent pathogens are; Strept. Pneumoniae , staph aureus, strept. Pyogenes & H influenzae - (under 5 yrs children)

10. Causes
Spread from the sinuses; mostly ethmoidal in children & young adults
Extension from preseptal cellulitis
Local spread; dacrocystitis, dental infection, facial infection, infection of the eyeball ( panophthalmitis etc)
Haemotogenous spread
Post- traumatic; accidental/ surgical

11. Clinical presentation
Symptoms; rapid onset painful swelling of the lids & protrusion of the eye, fever, malaise & visual loss ; history of risk factors
Signs; moderate to severe swelling of the lids, reduced visual acuity, proptosis,red eye with chemosis of the conjunctiva, abnormal & painful EOM & pupillary response

14. Complications
Ocular; corneal damage( exposure),raised IOP, vascular occlusions, optic nerve damage, endophthalmitis
Intracranial; meningitis, brain abscess, cavernous sinus thrombosis
Orbital abscess

17. Management Symptomatic; antipyretic, NSAIDS
Specific ; hospitalization & antibiotic therapy
Ceftazidime 1 g tds , I/M
Mteronidazole 500mg tds, PO
Vancomycin in case of allergy to the above mentioned
Surgical intervention in case of local abscess or unresponsive cases
Consultation with ENT specialist, neurosurgeon & paediatrician if required

18. Case #1
A 1 year old child presented to the OPD of department of ophthalmology with the complaint of a swollen right upper lid for the last two days. On examination the lid was red, warm & tender to touch. His visual acuity was normal, the eye had mild conjunctival redness, the pupil was normal and the ocular movements were also normal. Watch the photograph….

20. Some questions
Is the condition confined to the lids or has it involved the eyeball?
Why do you think so?
What more information would you like to have before making a diagnosis?

21. Some more information………
The child had a history of insect bite on the lid two days ago, the swelling increased thereafter. The insect bite mark was visible
There was no history of trauma or symptoms suggestive of sinusitis
His temperature was 990 F

22. Some more questions
What should be the management, keeping in mind the nature of the problem?
Is there any role of health education in this case?
Let us see an other case……..

23. Case #2
A seven year old child was brought the OPD of the department of ophthalmology with a history of swollen left upper lid for the last 5 days. He also had fever for the last two days. On examination the child had a grossly swollen lid. The doctor had difficulty in opening the lid for examination of the eye. The visual acuity was 6/6 OD & 6/18 OS. The lid was warm and tender. The eye was moderately proptosed with conjunctival chemosis. The pupil was slow to react to light and the ocular movements were painful & limited. The temperature was F & the child looked generally unwell……..

25. Some questions….
Is the condition confined to the lids or has it involved inner orbit?
What more information should we ask for to get an idea about the cause of the problem?

26. The child had a history of recurrent flu and upper respiratory tract infections. He had history of blocked nose and thick greenish nasal discharge was noted on examination.
The child was put on intravenous antibiotics but didn’t get better
Why?

27. The antibiotics were changed to intravenous ampicillin/sulbactam and after 5 days were changed to oral amoxicillin/clavulanic acid for a total of 14 days of antibiotics.

28. Some more questions
What should be the management, keeping in mind the nature of the problem?
What do you think can be done with the abscess?
Is there any role of health education in this case? ..

29. Conclusion about the two cases
What is the difference between the two cases?
We consider the second case an ocular emergency, why?
Why did the subperiosteal abscess form in the second case?
What other complications could happen in the second case?

30. Let us summarize
Preseptal orbital cellulitis & orbital cellulitis are both infections.
It is more common in children
The route of infection could be from the nearby infectious focus like infected sinuses, skin wound or spread of infection via blood
The most common cause especially in children is ethmoidal sinusitis

31. Both preseptal and orbital cellulitis may have:
Fever
Eyelid swelling
Pain
Red eye
Child is ill-appearing

32. Orbital cellulitis signifies spread of inflammation to the posterior orbital contents that is the eyeball, extraocular muscles: helpful signs to distinguish it are:-
Proptosis
Decreased visual acuity ( may be normal in the beginning)
Red eye with conjunctival chemosis of moderate to intense congestion
Painful limited eye movements
Afferent pupillary defect

33. Prior to the availability of antibiotics, patients with orbital cellulitis had a mortality rate of 17%, and 20% of survivors were blind in the affected eye. However, with prompt diagnosis and appropriate use of antibiotics, this rate has been reduced significantly
blindness can still occur in up to 11% of cases. Orbital cellulitis due to methicillin-resistant Staphylococcus aureus can lead to blindness despite antibiotic treatment.

34. Mortality/Morbidity:

35. BLOW-OUT FRACTURE OF THE ORBIT
Secondary to massive blow to the orbit resulting in fracture of one/ more of its walls ( mostly medial wall & floor)
Common in sports & violence related trauma
Mechanism involves sudden rise of intraorbital pressure & fracture of the bony socket at its weakest points

37. Clinical presentation
Symptoms ; history of trauma with double vision, pain in and around the orbit, visual loss ( not always)
Signs; periocular swelling, bruising ( ecchymosis), subcutaneous emphysema
Enophthlamos; in large & severe fractures & increases with time
Infraorbital nerve hypo/ anesthesia

38. Clinical presentation
EOM abnormalities; vertical diplopia, limited upgaze & downgaze --- floor fractures, limited adduction & abduction ---medial wall fracture
Ocular/ associated damage to the eyeball
Hyphaema RD
Damage to the angle of the anterior chamber—glaucoma
Vitreous haemorrhage
Orbital hematoma
Damage to the optic nerve

42. Complications EOM problems Visual loss Cosmetic
Secondary infection from the sinuses- orbital cellulitis & spread of the infected contents of the sinuses to the vital tissues like the eyeball & the brain

43. Investigations/ confirmatory tests
For confirmation of fracture
CT scan / X ray orbit
For confirmation of muscle entrapment
CT scan & forced duction test

45. Management
Symptomatic/ conservative: NSAID for relief of pain & reduction of inflammation ( discourage blowing of the nose to prevent forcing of the infected sinus contents into the orbit), antibiotics
If the diplopia persist beyond 2 weeks/ enophthamos is significant then surgical repair of the fracture with release of entrapped muscles may be required

46. Summary
Orbital cellulitis is a potentially vision threatening & life threatening disorder more commonly seen in children & young adults, requires hospitalization & intensive in-patient treatment
Blowout fracture is not a common disorder but is common in sports & violence related trauma, it can mostly be managed conservatively but in case of a large fracture or persistent EOM problems & enophthalmos may require surgical repair.

47. References
Orbit, eyelids & lacrimal system. American Academy of Ophthalmology;
Jack J Kanski. Clinical ophthalmology a systematic approach. 5th ed;2003:567-69,
Parsons’ diseases of the eye. Diseases of the adnexa-diseases of the orbit. 19th ed. 2004;
Newell F W. The orbit. In Ophthalmology principles & concepts.7th ed; 1992:259-69
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