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Toronto Notes 2019
The Orbit
Ophthalmology OP9
The Orbit
Globe Displacement
Table 5. Exophthalmos (Proptosis) and Enophthalmos
Definition
Investigations Etiology
Exophthalmos (Proptosis)
Anterior displacement (protrusion) of the globe
Exophthalmos generally refers to an endocrine etiology or protrusion of >18 mm (as measured by a Hertel exophthalmometer)
Proptosis generally refers to other etiologies (e.g. cellulitis) or protrusion of >18 mm
CT/MRI head/orbits, ultrasound orbits, thyroid function tests
Note: rule out pseudoexophthalmos (e.g. lid retraction)
Graves’ disease (unilateral or bilateral, most common causein adults) Orbital cellulitis (unilateral, most common cause in children)
1° or 2° orbital tumours
Orbital/retrobulbar hemorrhage
Cavernous sinus thrombosis or fistula
Enophthalmos
Posterior displacement (retraction) of the globe
CT/MRI orbits
“Blow-out” fracture (see Ocular Trauma,
OP39)
Orbital fat atrophy Congenital abnormality Metastatic disease
Preseptal Cellulitis
• infectionofsofttissueanteriortoorbitalseptum
Etiology
• usuallyfollowsperiorbitaltraumaordermalinfection
Clinical Features
Table 6. Clinical Features of Preseptal and Orbital Cellulitis
Finding
Fever
Lid edema Conjunctival Injection Chemosis
Proptosis
Pain on Eye Movement Ocular Mobility
Vision
RAPD
Leukocytosis
ESR
Additional Findings
Treatment
Preseptal Cellulitis
Orbital Cellulitis
Present
Severe
Present
Marked
Present
Present
Decreased Diminished ± diplopia May be seen if severe Marked
Elevated
Sinusitis, dental abscess
May be present Moderate to severe Absent
Absent
Absent
Absent
Normal
Normal
Absent
Moderate
Normal or elevated Skin infection
Role of Oral Corticosteroids in Orbital Cellulitis
Am J Ophthalmol 2013;156:178-183
Purpose: To evaluate the role of oral corticosteroids as an anti-inflammatory adjunct for the treatment of orbital cellulitis.
Study: RCT. Patients with acute onset (within 14
d) of orbital cellulitis with or without abscess.
21 patients total (7 patients in group 1: standard intravenous antibiotics; 14 patients in group 2: adjuvant steroids).
Results: Patients in group 2 showed earlier resolution of periorbital edema, conjunctival chemosis, pain, proptosis, and EOM deficits, including decreased duration of intravenous antibiotics and hospital stay (p<0.05 for all). Conclusion: The use of oral steroids as an adjunct to intravenous antibiotics for orbital cellulitis may decrease inflammatory symptoms with a low risk of worsening infection.
or mild
• systemicantibiotics(suspectH.influenzaeinchildren;S.aureusorStreptococcusinadults) ■ e.g. amoxicillin-clavulanic acid
• ifsevereorchild<1yr,treatasorbitalcellulitis
Orbital Cellulitis
• OCULARandMEDICALEMERGENCY
• inflammationoforbitalcontentsposteriortoorbitalseptum • commoninchildren,elderly,andimmunocompromised
Etiology
• usuallysecondarytosinus/facial/toothinfectionsortrauma,canalsoarisefrompreseptalcellulitis Clinical Features (see Table 6)
Treatment
• admit,bloodculturesx2,orbitalCT,IVantibiotics(ceftriaxone+vancomycin)for1wk • surgicaldrainageofabscesswithclosefollow-up,especiallyinchildren
Complications
• opticnerveinflammation,cavernoussinusthrombosis,meningitis,brainabscesswithpossiblelossof vision, and death