History

Fact Explanation
Introduction Orbit is a corn like bony space in the anterior skull. It mainly contains eye ball, ocular muscles, nerves and blood vessels. both orbits anteriorly eye ball connect with outer space posteriorly with the brain, superiorly with frontal sinus, inferiorly with maxillary(medially) and sphenoidal sinuses(laterally) and medially with ethmoidal sinus. Structures passing throught superior orbital fissure are oculomotor nerve, abducent nerve, naso ciliary branch of ophthalmic branch of trigeminal nerve and orbital veins. Optic nerve passes via optic foramen. Maxillary division of trigeminal nerve, zygomatic nerve, branches from the sphenopalatine ganglion and branches of inferior ophthalmic vein passes throught inferior orbital fissure. Maxillary division of trigeminal nerve passes via inferior maxillary groove. Anotomy of orbit and related structures are very important in identifying the aetiology, symptoms and complications of orbital infections[1][2][3].
fever, headache and other constitutional symptoms like malaise, lethargy, fatiguability fever, headache and other constitutional symptoms will be present due to the presence of an infection. In a presence of an abscess patient will have high grade fever[1][2].
Pain in the eyes and pain causing limitation of the eye movements Patients will complain pain eye pain it can be a continuous pain, or in early disease pain will present with movements of the eye ball. Pain is mainly due due to the inflammation of orbital muscles and swelling causing increased pressure in side the orbit. And also caused by the palsy of pupillary and ocular muscles causing limitation of eye functioning (poor vision may lead to eye pain). In periostitis pain can spread around the orbit as well. Pain will be deep, more towards the evening and will associated with headache and vomiting[1][3].
Swelling and redness around eyes and eye lids inflammation causes these symptoms[1][3].
Redness of the eye Chemosis following inflammatory processes (venous occlusion) causes painful red eye[5][6].
Numbness of the forehead Due to the inflammatory process following infection, nerve compression can cause numbness over supplying divisions (eg; ophthalmic branch of trigeminal nerve supply the forehead sensation)[7][8].
Photophobia Corneal damage, optic neuritis secondary to infection and dysfunction of pupils may lead to photophobia in a orbital infection. Afferent pupilary nerves can affect causing poor control over controlling the light entering to the eyes( due to afferent pupillary defects)[11][12].
eye ball projecting out than usual exophthalmos can develop following all infections of the orbit due to the increased intra-orbital pressure with soft tissue swelling and abscess formation[3][14].
Ulcers and pus discharging sinuses/ purulent nasal discharge Especially in periostitis of the orbital rim leads to abscess formation ultimately leading to ulceration and discharging fistula formation. This may be present as a purulent nasal discharge. These fistula common around eye lid and in chronic disease process like in osteomyelitis, these ulcers and fistulas can heal with fibrous formation causing contraction leading to eye lid deformities[13].
Visual impairment Compression of the optic nerve can cause visual problems this may range from mild visual impairment to sudden total loss of vision( sustained compression leads to optic nerve ischemia. Corneal damage (eg:direct trauma, keratitis), optic neuritis and blockage of ocular blood supply leads to visual problems[9][10].
Features suggestive of cavernous sinus thrombosis Cavernous sinus thrombosis is a complication of orbital infections. patient will have headache, periorbital pain, swelling and cranial nerve palsy ( Eg; Lateral gaze palsy with isolated cranial nerve VI, eye muscle weakness with 3rd cranial nerve palsy)[15][16].
Features suggestive of brain abscess Patient will have high grade fever, headache and focal neurological symptoms. Severity of the symptoms will depend on the size(usually occur in frontal lobe) and site of the abscess. Abscesses can be intracranial, epidural or subdural. Patient will persist symptoms despite of antibiotic therapy[17][18].
Features suggestive of meningitis Patient will have severe headache, photophobia, fever and altered behavior[19][20].
History of recent upper respiratory tract infections, Chronic sinusitis. paranasal sinusitis (headache, rhinorrhoea), periodontal abscesses (tooth ache with fever, tooth extraction), nasolacrimal infection (excessive tearing, pain/swelling of the medial aspect of the eye), otitis media(earache) and pharyngitis( difficulty/ pain during swallowing) like infections can leads to orbital cellulitis[3][21].
History of direct impact on eye Direct trauma to eye/surrounding structures, ophthalmic surgeries, foreign body in eye, insect bites can also leads to orbital infections[3][20][22].
Past history of lesions of the eye lid and lacrimal sac or past history of eyelid swelling, eye pain or excessive tearing. lesions of the eyelids and lacrimal sac by some infections like tuberculosis, syphilis and fungal infections can ultimately go into orbital infections especially periostitis of the orbit[23][24].
past history of diagnosed retinoblastoma or rhabdomyosarcoma in children or breast carcinoma Necrotic tumors like retinoblastoma, rhabdomyosarcoma will present as cellulitis of the orbit(aseptic). secondary metastatic deposits from primary cancers like breast cancers can also produce similar symptoms[25][26].
features of septicaemia In this case patient will be ill with constitutional symptoms, dizziness, there may be features of organ damage. Septicaemia can lead to cellulitis by haematogenous spread of the infections[3][20].
Age orbital infections are more common in younger population while it is more severe in adults[2][3].
sex In adult population there is no difference in sex distribution but in paediatric and young population males are at risk of developing orbital infections than females[4].
References
  1. ARMSTRONG PA, NICHOL NM. An eye for trouble: orbital cellulitis Emerg Med J [online] 2006 Dec, 23(12):e66 [viewed 11 October 2014] Available from: doi:10.1136/emj.2006.041194
  2. CLARKE WN. Periorbital and orbital cellulitis in children Paediatr Child Health [online] 2004 Sep, 9(7):471-472 [viewed 11 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2720862
  3. LAM CHOI VB, YUEN HK, BISWAS J, YANOFF M. Update in Pathological Diagnosis of Orbital Infections and Inflammations Middle East Afr J Ophthalmol [online] 2011, 18(4):268-276 [viewed 11 October 2014] Available from: doi:10.4103/0974-9233.90127
  4. PANDIAN DG, BABU RK, CHAITRA A, ANJALI A, RAO VA, SRINIVASAN R. Nine years' review on preseptal and orbital cellulitis and emergence of community-acquired methicillin-resistant Staphylococus aureus in a tertiary hospital in India Indian J Ophthalmol [online] 2011, 59(6):431-435 [viewed 11 October 2014] Available from: doi:10.4103/0301-4738.86309
  5. CHAUDHRY IA, AL-RASHED W, ARAT YO. The Hot Orbit: Orbital Cellulitis Middle East Afr J Ophthalmol [online] 2012, 19(1):34-42 [viewed 12 October 2014] Available from: doi:10.4103/0974-9233.92114
  6. WU JS. Orbital Cellulitis and Abscess West J Emerg Med [online] 2010 Sep, 11(4):398-399 [viewed 12 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2967699
  7. WIJNMAALEN A, VAN DER WERF-MESSING BH. Factors influencing the prognosis in bladder cancer. Int J Radiat Oncol Biol Phys [online] 1986 Apr, 12(4):559-65 [viewed 12 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/3700164
  8. YI WS, XU XL, MA JR, OU XR. Reconstruction of complex orbital fracture with titanium implants Int J Ophthalmol [online] , 5(4):488-492 [viewed 12 October 2014] Available from: doi:10.3980/j.issn.2222-3959.2012.04.16
  9. FLOOD TP, BRAUDE LS, JAMPOL LM, HERZOG S. Computed tomography in the management of orbital infections associated with dental disease. Br J Ophthalmol [online] 1982 Apr, 66(4):269-274 [viewed 12 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1039771
  10. COSTANTINIDES F, LUZZATI R, TOGNETTO D, BAZZOCCHI G, BIASOTTO M, TIRELLI GC. Rapidly progressing subperiosteal orbital abscess: an unexpected complication of a group-A streptococcal pharyngitis in a healthy young patient Head Face Med [online] :28 [viewed 12 October 2014] Available from: doi:10.1186/1746-160X-8-28
  11. DYLEWSKI JS, DRUMMOND R, TOWNSEND T. Orbital myositis complicating sinusitis Can J Infect Dis [online] 2001, 12(1):51-53 [viewed 12 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2094796
  12. JOHNSTON NR, AH-CHAN JJ, STEGEHUIS HR. Near-fatal subdural empyema complicating a rapidly progressive orbital cellulites J Emerg Trauma Shock [online] 2010, 3(3):295-297 [viewed 12 October 2014] Available from: doi:10.4103/0974-2700.66540
  13. PANDIAN DG, BABU RK, CHAITRA A, ANJALI A, RAO VA, SRINIVASAN R. Nine years' review on preseptal and orbital cellulitis and emergence of community-acquired methicillin-resistant Staphylococus aureus in a tertiary hospital in India Indian J Ophthalmol [online] 2011, 59(6):431-435 [viewed 12 October 2014] Available from: doi:10.4103/0301-4738.86309
  14. EMBONG Z, ISMAIL S, THANARAJ A, HUSSEIN A. Dental Infection Presenting with Ipsilateral Parapharyngeal Abscess and Contralateral Orbital Cellulitis - A Case Report Malays J Med Sci [online] 2007 Jul, 14(2):62-66 [viewed 12 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3442629
  15. ABSOUD M, HIKMET F, DEY P, JOFFE M, THAMBAPILLAI E. Bilateral cavernous sinus thrombosis complicating sinusitis J R Soc Med [online] 2006 Sep, 99(9):474-476 [viewed 12 October 2014] Available from: doi:10.1258/jrsm.99.9.474
  16. YARINGTON CT JR. Cavernous sinus thrombosis revisited. Proc R Soc Med [online] 1977 Jul, 70(7):456-459 [viewed 12 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1543142
  17. LEE S, YEN MT. Management of preseptal and orbital cellulitis Saudi J Ophthalmol [online] 2011 Jan, 25(1):21-29 [viewed 12 October 2014] Available from: doi:10.1016/j.sjopt.2010.10.004
  18. SIVAK-CALLCOTT JA, LIVESLEY N, NUGENT RA, RASMUSSEN SL, SAEED P, ROOTMAN J. Localised invasive sino-orbital aspergillosis: characteristic features Br J Ophthalmol [online] 2004 May, 88(5):681-687 [viewed 12 October 2014] Available from: doi:10.1136/bjo.2003.021725
  19. TOLE DM, ANDERTON LC, HAYWARD JM. Orbital cellulitis demands early recognition, urgent admission and aggressive management. J Accid Emerg Med [online] 1995 Jun, 12(2):151-153 [viewed 12 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1342559
  20. SHUTTLEWORTH GN, DAVID DB, POTTS MJ, BELL CN, GUEST PG. Orbital trauma: do not blow your nose BMJ [online] 1999 Apr 17, 318(7190):1054-1055 [viewed 12 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1115453
  21. DYLEWSKI JS, DRUMMOND R, TOWNSEND T. Orbital myositis complicating sinusitis Can J Infect Dis [online] 2001, 12(1):51-53 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2094796
  22. PARK CH, JEE DH, LA TY. A Case of Odontogenic Orbital Cellulitis Causing Blindness by Severe Tension Orbit J Korean Med Sci [online] 2013 Feb, 28(2):340-343 [viewed 13 October 2014] Available from: doi:10.3346/jkms.2013.28.2.340
  23. KLOTZ SA, PENN CC, NEGVESKY GJ, BUTRUS SI. Fungal and Parasitic Infections of the Eye Clin Microbiol Rev [online] 2000 Oct, 13(4):662-685 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC88956
  24. SHARMA K, KANAUJIA V, JAIN A, BAINS S, SUMAN S. Tuberculous Orbital Abscess Associated with Thyroid Tuberculosis J Ophthalmic Vis Res [online] 2011 Jul, 6(3):204-207 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3306106
  25. CHAUDHRY IA MD, PHD, FACS, SHAMSI FA MPHIL, PHD, ARAT YO MD, RILEY FC MD. Orbital Pseudotumor: Distinct Diagnostic Features and Management Middle East Afr J Ophthalmol [online] 2008, 15(1):17-27 [viewed 13 October 2014] Available from: doi:10.4103/0974-9233.53370
  26. ANSARI S, RAUNIYAR RK, DHUNGEL K, SAH PL, AHMAD K, GUPTA MK, AGRAWAL M. Acute myeloid leukemia presenting as bilateral proptosis and right temporal swelling Oman J Ophthalmol [online] 2014, 7(1):35-37 [viewed 13 October 2014] Available from: doi:10.4103/0974-620X.127927

Examination

Fact Explanation
General examination patient will be ill looking, in pain and febrile patient will have fever and other constitutional symptoms following infection of the orbit. Temberature should be measure and a chart should be maintained if the patient is in ward. In a presence of an abscess patient will have high grade fever[1][2].
Inspection of the eye 1) redness of eye lids and surrounding- Swelling and redness around the eye lids and surrounding area is caused by inflammation[1][3]. 2) Ptosis with swelling of eye lids- Swelling of the eye lids and surrounding area is caused by inflammation. Due to the swelling and presence of abscesses of the eye lid patient will have ptosis of the affected eye[1][3]. 3) chemosis- Chemosis occur following inflammatory processes (venous occlusion) and conjuctivitis. So this results painful red eye[4][5]. 3) ulceration of the eye lid and pus discharging fistulas- Especially periostitis of the orbital rim and in osteomyelitis leads to abscess formation ultimately leading to ulceration and discharging fistula formation. These fistula common around eye lid and in chronic disease process like in osteomyelitis 4) deformed eye lid- Ulcers and fistulas can heal with fibrous formation causing contraction leading to eye lid deformities like ectropion and entropian[6][7]. 5) Limted eye movements- Pain causes limitation of the eye movements which occur following inflammation and swelling of the orbital soft tissues and occular muscle palsy can also limit the movements[1][3]. 6) eye ball deviation- In the presence of orbital abscesses eye ball deviation can be seen to contralateral side due to the space limitation. Occular muscle palsy also can be a cause for this[8][9][10]. 7) exophthalmos- Soft tissue swelling with inflammation, abscess formation and osteomyelitis can cause protrusion of the eye ball causing exopthalmos[3][11]. 8) look for any evidence of surgical/ traumatic scars- Direct trauma to eye/surrounding structures, ophthalmic surgeries, foreign body in eye, insect bites can also leads to orbital infections.
palpation of surrounding of the eye 1) warmth and tenderness- Due to the inflammatory process the surrounding soft tissues will be warm and tender[1][2][3]. 2) crepitations over the bony segments- If the patient is having osteomyelitis of the orbital rim there will be tenderness over the orbital rim and crepitations can be feel[1][3][15]. 3) reduced/ absent sensation over fore head- Numbness/ absent sensation of the forehead is due to the inflammatory process. Following the infection nerve compression which are passing through the orbit can cause numbness over supplying divisions (eg; ophthalmic branch of trigeminal nerve supply the forehead sensation)[16][17].
Visual acuity Compression of the optic nerve can cause visual problems this may range from mild visual impairment to sudden total loss of vision( sustained compression leads to optic nerve ischemia). Corneal damage (either with direct impact or infection causing keratitis), optic neuritis and blockage of ocular blood supply also leads to visual problems[18][19].
colour vision Optic neuritis following infection of the orbit cause red colour blindness and patient will see red objects as pink or orange. Can use Ishihara color charts for assessment[20][21].
visual fields Visual field can limit following limitation of the eye movement and also with development of optic neuritis (eg: central scotomas, diffuse vision loss, hemianopia)[22][23].
accormadation and light reflex Three will be an accommodation and light reflex impairment with orbital infection due to poor pupillary reaction. There will be changes in perception of brightness which can assess using Pelli-Robson chart. So patient will have photophobia. Corneal damage can also leads to this[24][25].
fundoscopic examination Diffuse disk oedema, blurring of disk margins can be seen during inflammatory process. Prolonged infection/ ischemic conditions may lead to disk atrophy. In presence of an orbital abscess venous engorgement, papilledema will be seen. In retinoblastoma red reflex will be absent[26][27][28].
look for the signs of cavernous sinus thrombosis Patient will present with ptosis, chemosis, visual defects, cranial nerve palsies (III, IV, V, VI). In fundoscopic examination there will be papilledema and retinal hemorrhages[29][30].
look for the evidence of meningitis/ brain abscesses In meningitis patients will have fever, headache, photophobia and neck stiffness and there may be altered mental states[31][32]. In brain abscess patient will have high fever and features of space occupying lesion. Symptoms will depend on the site of abscess[33][34].
look for the evidence of any persistent upper/ lower respiratory tract infection. Auroscopic examination for suspected ortitis media. Patient will have fever, cough, rhinorrhoea, throat inflammation/ inflammed tonsils, ear discharge, tenderness over sinuses, dental caries.This is important as this can leads to orbital infections. (eg; paranasal sinusitis , periodontal abscesses, nasolacrimal infection, otitis media, pharyngitis) Feature suggestive of tuberculosis like loss of weight, low grade fever, chronic cough, haemoptysi and lung fibrosis also important as it leads to orbital infections[3][35].
Look for the evidence of septicaemia Patient will be ill, hyperthermic, hypotensive, tachycardic, tachypnic and there will be associated features of end organ failure. In septicaemia, haematogenous spread of organisms can cause orbital infections[3][32].
Breast examination (breast lump, ulceration, nipple discharge, skin changes) This will be useful in suspected case of breast secondaries causing orbital infection[3].
References
  1. ARMSTRONG PA, NICHOL NM. An eye for trouble: orbital cellulitis Emerg Med J [online] 2006 Dec, 23(12):e66 [viewed 11 October 2014] Available from: doi:10.1136/emj.2006.041194
  2. CLARKE WN. Periorbital and orbital cellulitis in children Paediatr Child Health [online] 2004 Sep, 9(7):471-472 [viewed 11 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2720862
  3. LAM CHOI VB, YUEN HK, BISWAS J, YANOFF M. Update in Pathological Diagnosis of Orbital Infections and Inflammations Middle East Afr J Ophthalmol [online] 2011, 18(4):268-276 [viewed 11 October 2014] Available from: doi:10.4103/0974-9233.90127
  4. CHAUDHRY IA, AL-RASHED W, ARAT YO. The Hot Orbit: Orbital Cellulitis Middle East Afr J Ophthalmol [online] 2012, 19(1):34-42 [viewed 12 October 2014] Available from: doi:10.4103/0974-9233.92114
  5. WU JS. Orbital Cellulitis and Abscess West J Emerg Med [online] 2010 Sep, 11(4):398-399 [viewed 12 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2967699
  6. PANDIAN DG, BABU RK, CHAITRA A, ANJALI A, RAO VA, SRINIVASAN R. Nine years' review on preseptal and orbital cellulitis and emergence of community-acquired methicillin-resistant Staphylococus aureus in a tertiary hospital in India Indian J Ophthalmol [online] 2011, 59(6):431-435 [viewed 12 October 2014] Available from: doi:10.4103/0301-4738.86309
  7. AL-SALEM KM, ALSARAYRA FA, SOMKAWAR AR. Neonatal orbital abscess Indian J Ophthalmol [online] 2014 Mar, 62(3):354-357 [viewed 13 October 2014] Available from: doi:10.4103/0301-4738.116447
  8. KHAN SN, SEPAHDARI AR. Orbital masses: CT and MRI of common vascular lesions, benign tumors, and malignancies Saudi J Ophthalmol [online] 2012 Oct, 26(4):373-383 [viewed 13 October 2014] Available from: doi:10.1016/j.sjopt.2012.08.001
  9. AGGARWAL SK, BHAVANA K, KESHRI A, KUMAR R, SRIVASTAVA A. Frontal sinus mucocele with orbital complications: Management by varied surgical approaches Asian J Neurosurg [online] 2012, 7(3):135-140 [viewed 13 October 2014] Available from: doi:10.4103/1793-5482.103718
  10. BLOMQUIST PH. METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS INFECTIONS OF THE EYE AND ORBIT (AN AMERICAN OPHTHALMOLOGICAL SOCIETY THESIS) Trans Am Ophthalmol Soc [online] 2006 Dec:322-345 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1809917
  11. EMBONG Z, ISMAIL S, THANARAJ A, HUSSEIN A. Dental Infection Presenting with Ipsilateral Parapharyngeal Abscess and Contralateral Orbital Cellulitis - A Case Report Malays J Med Sci [online] 2007 Jul, 14(2):62-66 [viewed 12 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3442629
  12. PARK CH, JEE DH, LA TY. A Case of Odontogenic Orbital Cellulitis Causing Blindness by Severe Tension Orbit J Korean Med Sci [online] 2013 Feb, 28(2):340-343 [viewed 13 October 2014] Available from: doi:10.3346/jkms.2013.28.2.340
  13. SHUTTLEWORTH GN, DAVID DB, POTTS MJ, BELL CN, GUEST PG. Orbital trauma: do not blow your nose BMJ [online] 1999 Apr 17, 318(7190):1054-1055 [viewed 12 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1115453
  14. KLAPPER SR, PATRINELY JR. Management of Cosmetic Eyelid Surgery Complications Semin Plast Surg [online] 2007 Feb, 21(1):80-93 [viewed 13 October 2014] Available from: doi:10.1055/s-2007-967753
  15. AHMAD SS, GHANI SA, PENG KS, SELLAMUTHU P. 5-year-old girl with left upper eyelid swelling Digit J Ophthalmol [online] , 18(4):15-17 [viewed 13 October 2014] Available from: doi:10.5693/djo.03.2012.05.001
  16. WIJNMAALEN A, VAN DER WERF-MESSING BH. Factors influencing the prognosis in bladder cancer. Int J Radiat Oncol Biol Phys [online] 1986 Apr, 12(4):559-65 [viewed 12 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/3700164
  17. YI WS, XU XL, MA JR, OU XR. Reconstruction of complex orbital fracture with titanium implants Int J Ophthalmol [online] , 5(4):488-492 [viewed 12 October 2014] Available from: doi:10.3980/j.issn.2222-3959.2012.04.16
  18. FLOOD TP, BRAUDE LS, JAMPOL LM, HERZOG S. Computed tomography in the management of orbital infections associated with dental disease. Br J Ophthalmol [online] 1982 Apr, 66(4):269-274 [viewed 12 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1039771
  19. COSTANTINIDES F, LUZZATI R, TOGNETTO D, BAZZOCCHI G, BIASOTTO M, TIRELLI GC. Rapidly progressing subperiosteal orbital abscess: an unexpected complication of a group-A streptococcal pharyngitis in a healthy young patient Head Face Med [online] :28 [viewed 12 October 2014] Available from: doi:10.1186/1746-160X-8-28
  20. QUIROS PA, TORRES RJ, SALOMAO S, BEREZOVSKY A, CARELLI V, SHERMAN J, SADUN F, DE NEGRI A, BELFORT R, SADUN AA. Colour vision defects in asymptomatic carriers of the Leber's hereditary optic neuropathy (LHON) mtDNA 11778 mutation from a large Brazilian LHON pedigree: a case-control study Br J Ophthalmol [online] 2006 Feb, 90(2):150-153 [viewed 03 October 2014] Available from: doi:10.1136/bjo.2005.074526
  21. KATZ B. The dyschromatopsia of optic neuritis: a descriptive analysis of data from the optic neuritis treatment trial. Trans Am Ophthalmol Soc [online] 1995:685-708 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/article/PMC1312075
  22. KELTNER JL, JOHNSON CA, CELLO KE, DONTCHEV M, GAL RL, BECK RW, FOR THE OPTIC NEURITIS STUDY GROUP. Visual Field Profile of Optic Neuritis: A Final Follow-up Report From the Optic Neuritis Treatment Trial From Baseline Through 15 Years Arch Ophthalmol [online] 2010 Mar, 128(3):330-337 [viewed 03 October 2014] Available from: doi:10.1001/archophthalmol.2010.16
  23. BEHBEHANI R. Clinical approach to optic neuropathies Clin Ophthalmol [online] 2007 Sep, 1(3):233-246 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2701125
  24. WAKAKURA M, YOKOE J. Evidence for preserved direct pupillary light response in Leber's hereditary optic neuropathy. Br J Ophthalmol [online] 1995 May, 79(5):442-446 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC505132
  25. BROADWAY DC. How to test for a relative afferent pupillary defect (RAPD) Community Eye Health [online] 2012, 25(79-80):58-59 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3588138
  26. AYDIN E, AKKUZU G, AKKUZU B, BILEZIKCI B. Frontal mucocele with an accompanying orbital abscess mimicking a fronto-orbital mucocele: case report BMC Ear Nose Throat Disord [online] :6 [viewed 13 October 2014] Available from: doi:10.1186/1472-6815-6-6
  27. SHARPE JA, SANDERS MD. Atrophy of myelinated nerve fibres in the retina in optic neuritis. Br J Ophthalmol [online] 1975 Apr, 59(4):229-232 [viewed 03 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1042599
  28. PATEL RM, AAKALU VK, JOE S, SETABUTR P. An Abscess Causing a Delayed Optic Neuropathy After Decompression for Thyroid Eye Disease Orbit [online] 2014 Feb, 33(1):65-67 [viewed 13 October 2014] Available from: doi:10.3109/01676830.2013.842256
  29. ABSOUD M, HIKMET F, DEY P, JOFFE M, THAMBAPILLAI E. Bilateral cavernous sinus thrombosis complicating sinusitis J R Soc Med [online] 2006 Sep, 99(9):474-476 [viewed 12 October 2014] Available from: doi:10.1258/jrsm.99.9.474
  30. YARINGTON CT JR. Cavernous sinus thrombosis revisited. Proc R Soc Med [online] 1977 Jul, 70(7):456-459 [viewed 12 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1543142
  31. TOLE DM, ANDERTON LC, HAYWARD JM. Orbital cellulitis demands early recognition, urgent admission and aggressive management. J Accid Emerg Med [online] 1995 Jun, 12(2):151-153 [viewed 12 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1342559
  32. SHUTTLEWORTH GN, DAVID DB, POTTS MJ, BELL CN, GUEST PG. Orbital trauma: do not blow your nose BMJ [online] 1999 Apr 17, 318(7190):1054-1055 [viewed 12 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1115453
  33. LEE S, YEN MT. Management of preseptal and orbital cellulitis Saudi J Ophthalmol [online] 2011 Jan, 25(1):21-29 [viewed 12 October 2014] Available from: doi:10.1016/j.sjopt.2010.10.004
  34. SIVAK-CALLCOTT JA, LIVESLEY N, NUGENT RA, RASMUSSEN SL, SAEED P, ROOTMAN J. Localised invasive sino-orbital aspergillosis: characteristic features Br J Ophthalmol [online] 2004 May, 88(5):681-687 [viewed 12 October 2014] Available from: doi:10.1136/bjo.2003.021725
  35. DYLEWSKI JS, DRUMMOND R, TOWNSEND T. Orbital myositis complicating sinusitis Can J Infect Dis [online] 2001, 12(1):51-53 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2094796

Differential Diagnoses

Fact Explanation
cavernous sinus thrombosis Following other cause of intracranial venous thrombosis patient will present with cavernous sinus thrombosis. The features will be headache, oedematous eyelid, chemosis, proptosis and opthalmoplegia and simptoms of cranial nerve palsy. This can be diagnosed with MRI venogram[3][4].
Acute angle-closure glaucoma This is an acute presentation of painful red eye associated with severe eye pain, reduction of vision, photophobia, headache, nausea and vomiting. patient will have increased intraocular pressure [1][2].
Homonal imbalance causing graves' disease In graves disease there will be periorbital oedema, conjunctival irritation, exopthalmos and diplopia. In here patient's will have other thyrotoxic features and investigastions will confirm the thyrotoxicosis[5][6].
Allergy Alleric condition can leads to redness, itching and swelling of the eye. But tis will be reversible with the removal of the allergen and also it will associated with other symptoms like pruritic skin rash, wheezing, difficulty in breathing[7][8].
Sinusitis Sinusitis can will give pain over the eye causing visual defects due the pressure following inflammatory condition. symptoms will improve with the improvement of sinisitis. Sinus view of the X ray will confirm the ongoing sinusitis[9][10].
Optic neuritis This is an inflammatory condition of the optic nerve causing swelling and demyelination. This condition affects the vision of the patient. Other than orbital cellulitis there are common causes like multiple sclerosis which can cause this condition. Patient will have focal neurologcal signs as well. CT scan of the brain will help in identifying the lesions of multiple sclerosis[11][12].
References
  1. SEE JL, AQUINO MC, ADUAN J, CHEW PT. Management of angle closure glaucoma Indian J Ophthalmol [online] 2011 Jan, 59(Suppl1):S82-S87 [viewed 11 October 2014] Available from: doi:10.4103/0301-4738.73690
  2. AH-KEE EY, LI YIM JF. Bilateral acute angle closure glaucoma precipitated by over the counter oral decongestant Int J Ophthalmol [online] , 7(2):387-388 [viewed 11 October 2014] Available from: doi:10.3980/j.issn.2222-3959.2014.02.35
  3. ZAHLLER M, SPECTOR RH, SKOGLUND RR, DIGBY D, NYHAN WL. Cavernous sinus thrombosis. West J Med [online] 1980 Jul, 133(1):44-48 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1272185
  4. CLIFFORD-JONES RE, ELLIS CJ, STEVENS JM, TURNER A. Cavernous sinus thrombosis. J Neurol Neurosurg Psychiatry [online] 1982 Dec, 45(12):1092-1097 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC491689
  5. DE BRUIN TW, PATWARDHAN NA, BROWN RS, BRAVERMAN LE. Graves' disease: changes in TSH receptor and anti-microsomal antibodies after thyroidectomy. Clin Exp Immunol [online] 1988 Jun, 72(3):481-485 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1541569
  6. BAHN R. Autoimmunity and Graves Disease Clin Pharmacol Ther [online] 2012 Apr, 91(4):577-579 [viewed 13 October 2014] Available from: doi:10.1038/clpt.2012.10
  7. SAMI MS, SOPARKAR CN, PATRINELY JR, TOWER RN. Eyelid Edema Semin Plast Surg [online] 2007 Feb, 21(1):24-31 [viewed 13 October 2014] Available from: doi:10.1055/s-2007-967744
  8. MISHRA GP, TAMBOLI V, JWALA J, MITRA AK. Recent Patents and Emerging Therapeutics in the Treatment of Allergic Conjunctivitis Recent Pat Inflamm Allergy Drug Discov [online] 2011 Jan, 5(1):26-36 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3164156
  9. KERN EB, SHERRIS D, STERGIOU AM, KATZ LM, ROSENBLATT LC, PONIKAU J. Diagnosis and treatment of chronic rhinosinusitis: focus on intranasal Amphotericin B Ther Clin Risk Manag [online] 2007 Jun, 3(2):319-325 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1936313
  10. MELTZER EO, HAMILOS DL. Rhinosinusitis Diagnosis and Management for the Clinician: A Synopsis of Recent Consensus Guidelines Mayo Clin Proc [online] 2011 May, 86(5):427-443 [viewed 13 October 2014] Available from: doi:10.4065/mcp.2010.0392
  11. HUTCHINSON WM. Acute optic neuritis and the prognosis for multiple sclerosis. J Neurol Neurosurg Psychiatry [online] 1976 Mar, 39(3):283-289 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC492267
  12. BEHBEHANI R. Clinical approach to optic neuropathies Clin Ophthalmol [online] 2007 Sep, 1(3):233-246 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2701125

Investigations - for Diagnosis

Fact Explanation
Full blood count this will give an idea of anaemia by haemoglobin level and presence of infection by WBC count[2][3].
ESR, CRP These test will be high due to the ongoing inflammatory process[4].
Swab from eye dischare and drained pus from orbital abscesses for culture and ABST This will be helpful in identifying the causative infection and this will support the treatment[5][6][7]. eg: orbital infections -Staphylococcus aureus, Staphylococcus epidermidis, Streptococci, Diphtheroids, Haemophilus influenza, Escherichia coli orbital cellulitis- Haemophilus influenza
Blood culture In suspecting septicaemic condition this will be helpful to identify the organism[8][9].
Contrast-enhanced CT scan/ MRI This is useful in assessing walls of the orbital, periostium, orbital soft tissues, muscles and optic nerve and associated sinusitis. Contrast enhance CT will make orbital infections more prominent[1]. These also useful in identifying meningitis and brain abscesses[10][11].
ultrasound diagnosis This is useful in orbital abscess[1][12].
CSF studies( CSF full report, CSF culturs and ABST) CSF studies will useful in suspecting meningitis[13][14].
Sinus view of the Skull X ray This will important in suspected sinusitis(with air fluid levels) as predisposing cause of the orbital infection[15][16].
MR venogram this is more sensitive in diagnosing cavernous sinus thrombosis[17][18].
Chest X ray and sputum for Acid Fast Bacilli This is useful in suspecting tuberculosis[19][20].
mammogram/ Ultrasound scan of the breast and bone scan. This will be useful in suspected case of breast secondaries causing orbital infection[21][22].
Thyroid function tests( third generation TSH and T4) As thyrotoxicosis causing graves' disease, can give similer features these test will be useful in excluding differential diagnosis[23][24].
References
  1. CHAUDHRY IA, AL-RASHED W, ARAT YO. The Hot Orbit: Orbital Cellulitis Middle East Afr J Ophthalmol [online] 2012, 19(1):34-42 [viewed 09 October 2014] Available from: doi:10.4103/0974-9233.92114
  2. JOHNSON-WIMBLEY TD, GRAHAM DY. Diagnosis and management of iron deficiency anemia in the 21st century Therap Adv Gastroenterol [online] 2011 May, 4(3):177-184 [viewed 13 October 2014] Available from: doi:10.1177/1756283X11398736
  3. GROENEVELD AB, BOSSINK AW, VAN MIERLO GJ, HACK CE. Circulating Inflammatory Mediators in Patients with Fever: Predicting Bloodstream Infection Clin Diagn Lab Immunol [online] 2001 Nov, 8(6):1189-1195 [viewed 13 October 2014] Available from: doi:10.1128/CDLI.8.6.1189-1195.2001
  4. HEIDARI B. The importance of C-reactive protein and other inflammatory markers in patients with chronic obstructive pulmonary disease Caspian J Intern Med [online] 2012, 3(2):428-435 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3861908
  5. PANDIAN DG, BABU RK, CHAITRA A, ANJALI A, RAO VA, SRINIVASAN R. Nine years' review on preseptal and orbital cellulitis and emergence of community-acquired methicillin-resistant Staphylococus aureus in a tertiary hospital in India Indian J Ophthalmol [online] 2011, 59(6):431-435 [viewed 13 October 2014] Available from: doi:10.4103/0301-4738.86309
  6. SO WL, HARDY TG. Aspergillus niger Infection of an Orbital Exenteration Socket Can Be Treated with Oral Itraconazole Case Rep Ophthalmol Med [online] 2012:763651 [viewed 13 October 2014] Available from: doi:10.1155/2012/763651
  7. CHUNG WC, LIN HJ, FOO NP, CHEN KT. Infantile orbital abscess caused by community-acquired methicillin-resistant Staphylococcus aureus J Ophthalmic Inflamm Infect [online] , 1(4):181-183 [viewed 13 October 2014] Available from: doi:10.1007/s12348-011-0030-1
  8. HENRY NK, MCLIMANS CA, WRIGHT AJ, THOMPSON RL, WILSON WR, WASHINGTON JA 2ND. Microbiological and clinical evaluation of the isolator lysis-centrifugation blood culture tube. J Clin Microbiol [online] 1983 May, 17(5):864-869 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC272757
  9. AUCKENTHALER R, ILSTRUP DM, WASHINGTON JA 2ND. Comparison of recovery of organisms from blood cultures diluted 10% (volume/volume) and 20% (volume/volume). J Clin Microbiol [online] 1982 May, 15(5):860-864 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC272203
  10. LAM CHOI VB, YUEN HK, BISWAS J, YANOFF M. Update in Pathological Diagnosis of Orbital Infections and Inflammations Middle East Afr J Ophthalmol [online] 2011, 18(4):268-276 [viewed 13 October 2014] Available from: doi:10.4103/0974-9233.90127
  11. KHAN SN, SEPAHDARI AR. Orbital masses: CT and MRI of common vascular lesions, benign tumors, and malignancies Saudi J Ophthalmol [online] 2012 Oct, 26(4):373-383 [viewed 13 October 2014] Available from: doi:10.1016/j.sjopt.2012.08.001
  12. KANG TL, SEIF D, CHILSTROM M, MAILHOT T. Ocular Ultrasound Identifies Early Orbital Cellulitis West J Emerg Med [online] 2014 Jul, 15(4):394 [viewed 13 October 2014] Available from: doi:10.5811/westjem.2014.4.22007
  13. TEBRUEGGE M, CURTIS N. Epidemiology, Etiology, Pathogenesis, and Diagnosis of Recurrent Bacterial Meningitis Clin Microbiol Rev [online] 2008 Jul, 21(3):519-537 [viewed 13 October 2014] Available from: doi:10.1128/CMR.00009-08
  14. DUNBAR SA, EASON RA, MUSHER DM, CLARRIDGE JE III. Microscopic Examination and Broth Culture of Cerebrospinal Fluid in Diagnosis of Meningitis J Clin Microbiol [online] 1998 Jun, 36(6):1617-1620 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC104888
  15. REULER JB, LUCAS LM, KUMAR KL. Sinusitis. A review for generalists. West J Med [online] 1995 Jul, 163(1):40-48 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1302915
  16. PHILLIPS JE, JI L, RIVELLI MA, CHAPMAN RW, CORBOZ MR. Three-dimensional analysis of rodent paranasal sinus cavities from X-ray computed tomography (CT) scans Can J Vet Res [online] 2009 Jul, 73(3):205-211 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2705075
  17. VERMA R, JUNEWAR V, SINGH RK, RAM H, PAL US. Bilateral cavernous sinus thrombosis and facial palsy as complications of dental abscess Natl J Maxillofac Surg [online] 2013, 4(2):252-255 [viewed 13 October 2014] Available from: doi:10.4103/0975-5950.127664
  18. ALVIS-MIRANDA HR, MILENA CASTELLAR-LEONES S, ALCALA-CERRA G, RAFAEL MOSCOTE-SALAZAR L. Cerebral sinus venous thrombosis J Neurosci Rural Pract [online] 2013, 4(4):427-438 [viewed 13 October 2014] Available from: doi:10.4103/0976-3147.120236
  19. ŞAHIN F, YıLDıZ P. Characteristics of endobronchial tuberculosis patients with negative sputum acid-fast bacillus J Thorac Dis [online] 2013 Dec, 5(6):764-770 [viewed 13 October 2014] Available from: doi:10.3978/j.issn.2072-1439.2013.12.15
  20. SWAI HF, MUGUSI FM, MBWAMBO JK. Sputum smear negative pulmonary tuberculosis: sensitivity and specificity of diagnostic algorithm BMC Res Notes [online] :475 [viewed 13 October 2014] Available from: doi:10.1186/1756-0500-4-475
  21. GRAHAM LJ, SHUPE MP, SCHNEBLE EJ, FLYNT FL, CLEMENSHAW MN, KIRKPATRICK AD, GALLAGHER C, NISSAN A, HENRY L, STOJADINOVIC A, PEOPLES GE, SHUMWAY NM. Current Approaches and Challenges in Monitoring Treatment Responses in Breast Cancer J Cancer [online] , 5(1):58-68 [viewed 13 October 2014] Available from: doi:10.7150/jca.7047
  22. GRAHAM LJ, SHUPE MP, SCHNEBLE EJ, FLYNT FL, CLEMENSHAW MN, KIRKPATRICK AD, GALLAGHER C, NISSAN A, HENRY L, STOJADINOVIC A, PEOPLES GE, SHUMWAY NM. Current Approaches and Challenges in Monitoring Treatment Responses in Breast Cancer J Cancer [online] , 5(1):58-68 [viewed 13 October 2014] Available from: doi:10.7150/jca.7047
  23. O'REILLY DS. Thyroid function tests--time for a reassessment BMJ [online] 2000 May 13, 320(7245):1332-1334 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1127319
  24. AFSAR FS, ISLETEN F. Prevalence of thyroid function test abnormalities and thyroid autoantibodies in children with vitiligo Indian J Endocrinol Metab [online] 2013, 17(6):1096-1099 [viewed 13 October 2014] Available from: doi:10.4103/2230-8210.122636

Investigations - Fitness for Management

Fact Explanation
full blood count This will give an idea of anaemia by haemoglobin level and presence of infection by WBC count during the follow up[1][2].
ESR, CRP This is useful in assesssing the ongoing inflammatory process[2].
Blood culture In a suspected septicemic condition this test will be useful during the follow up[3][4].
CT scan/ MRI As this is useful in assessing walls of the orbital, periostium, orbital soft tissues, muscles and optic nerve and associated sinusitis. CT/ MRI will be useful during follow up to assess the condition of the orbital infetion and also useful in identifying meningitis and brain abscesses[5][6].
Ultrasound scan This will be useful in assessing the soft tissue of the orbit. Mare important in the presence of orbital abscesses[7][8].
References
  1. JOHNSON-WIMBLEY TD, GRAHAM DY. Diagnosis and management of iron deficiency anemia in the 21st century Therap Adv Gastroenterol [online] 2011 May, 4(3):177-184 [viewed 13 October 2014] Available from: doi:10.1177/1756283X11398736
  2. GROENEVELD AB, BOSSINK AW, VAN MIERLO GJ, HACK CE. Circulating Inflammatory Mediators in Patients with Fever: Predicting Bloodstream Infection Clin Diagn Lab Immunol [online] 2001 Nov, 8(6):1189-1195 [viewed 13 October 2014] Available from: doi:10.1128/CDLI.8.6.1189-1195.2001
  3. HENRY NK, MCLIMANS CA, WRIGHT AJ, THOMPSON RL, WILSON WR, WASHINGTON JA 2ND. Microbiological and clinical evaluation of the isolator lysis-centrifugation blood culture tube. J Clin Microbiol [online] 1983 May, 17(5):864-869 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC272757
  4. AUCKENTHALER R, ILSTRUP DM, WASHINGTON JA 2ND. Comparison of recovery of organisms from blood cultures diluted 10% (volume/volume) and 20% (volume/volume). J Clin Microbiol [online] 1982 May, 15(5):860-864 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC272203
  5. KHAN SN, SEPAHDARI AR. Orbital masses: CT and MRI of common vascular lesions, benign tumors, and malignancies Saudi J Ophthalmol [online] 2012 Oct, 26(4):373-383 [viewed 13 October 2014] Available from: doi:10.1016/j.sjopt.2012.08.001
  6. LAM CHOI VB, YUEN HK, BISWAS J, YANOFF M. Update in Pathological Diagnosis of Orbital Infections and Inflammations Middle East Afr J Ophthalmol [online] 2011, 18(4):268-276 [viewed 13 October 2014] Available from: doi:10.4103/0974-9233.90127
  7. KANG TL, SEIF D, CHILSTROM M, MAILHOT T. Ocular Ultrasound Identifies Early Orbital Cellulitis West J Emerg Med [online] 2014 Jul, 15(4):394 [viewed 13 October 2014] Available from: doi:10.5811/westjem.2014.4.22007
  8. CHAUDHRY IA, AL-RASHED W, ARAT YO. The Hot Orbit: Orbital Cellulitis Middle East Afr J Ophthalmol [online] 2012, 19(1):34-42 [viewed 09 October 2014] Available from: doi:10.4103/0974-9233.92114

Investigations - Followup

Fact Explanation
Ultrasound scan This is useful in assessing( respond to treatment) the orbital abscess in followup. Also will useful for ultrasound guided aspiration[1][2].
References
  1. KANG TL, SEIF D, CHILSTROM M, MAILHOT T. Ocular Ultrasound Identifies Early Orbital Cellulitis West J Emerg Med [online] 2014 Jul, 15(4):394 [viewed 13 October 2014] Available from: doi:10.5811/westjem.2014.4.22007
  2. KANG TL, SEIF D, CHILSTROM M, MAILHOT T. Ocular Ultrasound Identifies Early Orbital Cellulitis West J Emerg Med [online] 2014 Jul, 15(4):394 [viewed 13 October 2014] Available from: doi:10.5811/westjem.2014.4.22007

Investigations - Screening/Staging

Fact Explanation
Orbital infections classification by Smith and Spencer and modified by Chandler Preseptal cellulitis as Group I Orbital cellulitis as Group II Subperiosteal abscess as as Group III Orbital abscess as as Group IV Cavernous sinus thrombosis as as Group V[1][2]
ultrasound diagnosis This is useful in screening the presence of orbital infections[1][3]
References
  1. CHAUDHRY IA, AL-RASHED W, ARAT YO. The Hot Orbit: Orbital Cellulitis Middle East Afr J Ophthalmol [online] 2012, 19(1):34-42 [viewed 09 October 2014] Available from: doi:10.4103/0974-9233.92114
  2. GONZALEZ MO, DURAIRAJ VD. Understanding Pediatric Bacterial Preseptal and Orbital Cellulitis Middle East Afr J Ophthalmol [online] 2010, 17(2):134-137 [viewed 14 October 2014] Available from: doi:10.4103/0974-9233.63074
  3. KANG TL, SEIF D, CHILSTROM M, MAILHOT T. Ocular Ultrasound Identifies Early Orbital Cellulitis West J Emerg Med [online] 2014 Jul, 15(4):394 [viewed 13 October 2014] Available from: doi:10.5811/westjem.2014.4.22007

Management - General Measures

Fact Explanation
Health education Patient/ care givers must be educated about the disease, possible predisposing factors, complications associated with the disease, prognosis, investigation options available and treatment options[1][2].
Eye care This is very important in protecting the eye. Eye should be keep clean and should be handle with sterile glove worn hands. saline socked cotton wools can be used to clean the eyes. Due to the inflammatory process and proptosis eye is more prone to dry causing corneal damage. If the eye is difficult to close it should be cover with a sterile, saline socked gause piece. Artifial tear can use to keep moisture. Need to check the blink response and if the response is absent better to keep the eyes cover and closed. If the eye lid is not closing spontaneously, it should be close manually. Eye need to be examined regularly and complications need to be identify and teat promptly. If there are any predisposing factors for orbital infections as mentioned in the history they should be treated and eye should be regularly monitored [3][4][5][6].
References
  1. DERRYBERRY M. Today's Health Problems and Health Education Am J Public Health [online] 2004 Mar, 94(3):368-371 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1448258
  2. WINKLEBY MA, JATULIS DE, FRANK E, FORTMANN SP. Socioeconomic status and health: how education, income, and occupation contribute to risk factors for cardiovascular disease. Am J Public Health [online] 1992 Jun, 82(6):816-820 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1694190
  3. AZFAR MF, KHAN MF, ALZEER AH. Protocolized eye care prevents corneal complications in ventilated patients in a medical intensive care unit Saudi J Anaesth [online] 2013, 7(1):33-36 [viewed 15 October 2014] Available from: doi:10.4103/1658-354X.109805
  4. ALEXANDER RL JR, MILLER NA, COTCH MF, JANISZEWSKI R. Factors That Influence the Receipt of Eye Care Am J Health Behav [online] 2008, 32(5):547-556 [viewed 15 October 2014] Available from: doi:10.5555/ajhb.2008.32.5.547
  5. WILL JC, GERMAN RR, SCHUMAN E, MICHAEL S, KURTH DM, DEEB L. Patient adherence to guidelines for diabetes eye care: results from the diabetic eye disease follow-up study. Am J Public Health [online] 1994 Oct, 84(10):1669-1671 [viewed 15 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1615103
  6. IMPORTANCE OF AFFORDABLE EYE CARE Community Eye Health [online] 2001, 14(37):1-3 [viewed 15 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1705912

Management - Specific Treatments

Fact Explanation
Start broad spectrum IV antibiotics Iv broad spectrum antibiotis (eg; erythromycin, penicillin, chloramphenicol, cephalosporin) should be started as soon as possible after taking blood/eye discharge/ nasal discharge for culture. Drugs should be continued until the reports comes. If the patient is well responding to the already started antibiotics better to continue that thought the reports recommended others. But if the patient is not/ poorly responding report findings will be treatment of choice[1][2].
Drainage of the abscesses according to the ultrasound scan findings if the abscess it small, patient can be treated with broad spectrum antibiotics and look for improvement. But if the abscess is large/ patient is not responding to the. treatments drainage of the abscess can be consider. Drained pus should be send to culture and ABST, can continue previous IV antibiotic till the report comes and then if needed can shift to another sensitive antibiotic. In here both aerobic and anaerobic organisms should be covered[3][4].
Orbital periostitis treatment Iv broadspectrum antibiotics should be started after taking the blood and discharge swabs for culture and ABST. If there are associated abcessess incision and drainage must be consider and sample must be send to culture and ABST. If associated fistula present appropriate surgical treatment must be consider (eg: resection/ sequestration)[2][5].
osteomyelitis treatment Similer to other three conditions treatment should be started with IV high dose broad-spectrum antibioticples. Surgical treatment should be consider for not responding abscesses( incision and drainage) and fistulas (eg:resection/ sequestration). If there are Permanent eyelid deformities (eg: ectropian, entropion) will require surgical correction. With the osteomyelitis there can be underlyinfg bony destruction, necrosis So those should be identify and surgical removal should be done. This will help antibiotics to act on causative organisms. As the superior roof of the orbit is separate the orbital content from the anterior fossa of the skull, osteomylitis involving this part can spread to the skull. So carefull examination should be done to identify any damages and if damages are present repair need to be done[6][7].
Cavernous sinus thrombosis management Intravenous empiric antibiotic therapy (eg; penicillin, cephalosporin) should be given with anaerobic coverage. This should be given for long duration, at least for one month. Some studies have shown the use of anticoagulant with heparin is life saving and improves the out come. Streptokinase and other fibrinolytic s need to be used via selective catheterization[8][9].
Meningitis management IV empirical antibiotic treatment (eg; Benzylpenicillin 2.4g IV 6 hourly) should be consider after taking CSF for studies[10][11].
Brain abscess management First patient should be given IV antibiotics and if not responding surgical evacuation of te abscess should be considered (eg; burr- hole aspiration or excision) as encapsulated abscess will provide a protective medium to persist the infection[12][13].
Treat upper respiratory tract infection/ chronic sinusitis If this conditions identified as the primary source they should be treated first. eg: 1)Acute coryza- Paracetamol 0.5-1g 6 hourly will improve symptoms, nasal decongestants will be helpful, antibiotics will not necessary in uncomplicated cases. 2) Acute laryngitis- resting, paracetamol and steam inhalation will be useful. 3) Acute laryogo tracheobronchitis- steam inhalation, oxygen therapy will needed, endotracheal intubation/ tracheostomy will relief the symptoms. IV antibiotic therapy (eg;co-amoxyclav, eruthromycin) will helpful in severe disease. 4) Acute bronchitis and tracheitis- Amoxicillin 250mg 8 hourly will be useful. 5) Chronic sinusitis- First can treated with antibiotics (eg; Penicillins, Cephalosporins, Macrolides, Fluoroquinolones) and if not responding drainage can be done. Functional endoscopic sinus surgery proven to be effective in chronic sinusitis[14][15].
If patient is suspected to have neoplastic condition as the primary cause Surgical treatement,chemotherapy anf radiotherapy will be helpful with the oncologist's openion. Retinoblastoma- Enucliation of the eye will be needed in advanced disease and if bilateral chemotherapy will be needed following retinal laser treatment. Radiotherapy will use in recurrences[16]. Rhabdomyosarcoma- depending on the severity of the disease surgery, cemotherapy anfd radiotherapy can be used[17].
References
  1. CHAUDHRY IA, AL-RASHED W, ARAT YO. The Hot Orbit: Orbital Cellulitis Middle East Afr J Ophthalmol [online] 2012, 19(1):34-42 [viewed 13 October 2014] Available from: doi:10.4103/0974-9233.92114
  2. LAM CHOI VB, YUEN HK, BISWAS J, YANOFF M. Update in Pathological Diagnosis of Orbital Infections and Inflammations Middle East Afr J Ophthalmol [online] 2011, 18(4):268-276 [viewed 13 October 2014] Available from: doi:10.4103/0974-9233.90127
  3. AL-SALEM KM, ALSARAYRA FA, SOMKAWAR AR. Neonatal orbital abscess Indian J Ophthalmol [online] 2014 Mar, 62(3):354-357 [viewed 13 October 2014] Available from: doi:10.4103/0301-4738.116447
  4. DECROOS F, LIAO J, RAMEY N, LI I. Management of Odontogenic Orbital Cellulitis J Med Life [online] 2011 Aug 15, 4(3):314-317 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3168817
  5. BABU K, MUKHOPADHYAY M, BHAT SS, CHINMAYEE J. Orbital and adnexal tuberculosis: a case series from a South Indian population J Ophthalmic Inflamm Infect [online] :12 [viewed 13 October 2014] Available from: doi:10.1186/1869-5760-4-12
  6. FRAIMOW HS. Systemic Antimicrobial Therapy in Osteomyelitis Semin Plast Surg [online] 2009 May, 23(2):90-99 [viewed 13 October 2014] Available from: doi:10.1055/s-0029-1214161
  7. HARIK NS, SMELTZER MS. Management of acute hematogenous osteomyelitis in children Expert Rev Anti Infect Ther [online] 2010 Feb, 8(2):175-181 [viewed 13 October 2014] Available from: doi:10.1586/eri.09.130
  8. ABSOUD M, HIKMET F, DEY P, JOFFE M, THAMBAPILLAI E. Bilateral cavernous sinus thrombosis complicating sinusitis J R Soc Med [online] 2006 Sep, 99(9):474-476 [viewed 13 October 2014] Available from: doi:10.1258/jrsm.99.9.474
  9. KELEN A. CAVERNOUS SINUS THROMBOSIS Can Med Assoc J [online] 1947 Dec, 57(6):578-581 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1590704
  10. HOFFMAN O, WEBER RJ. Pathophysiology and Treatment of Bacterial Meningitis Ther Adv Neurol Disord [online] 2009 Nov, 2(6):1-7 [viewed 13 October 2014] Available from: doi:10.1177/1756285609337975
  11. HUMPHRIES M. The management of tuberculous meningitis. Thorax [online] 1992 Aug, 47(8):577-581 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC463911
  12. KING JE, TURNEY F. Brain Abscess: Evolution of the Methods of Treatment Ann Surg [online] 1954 May, 139(5):587-610 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1609570
  13. BELLER AJ, SAHAR A, PRAISS I. Brain abscess: Review of 89 cases over a period of 30 years J Neurol Neurosurg Psychiatry [online] 1973 Oct, 36(5):757-768 [viewed 13 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC494454
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