terça-feira, 10 de novembro de 2009

CELULITE OCULAR-ORBITAL E PERIORBITAL



What are the physical findings that distinguish periorbital from orbital cellulitis?
Periorbital
Orbital
Fever
Fever
Lid warmth, edema, erythema, and tenderness
Lid warmth, edema, erythema, and tenderness
Red eye
Red eye
Conjunctivitis
Conjunctivitis

Chemosis

Periocular pain

Decreased extraocular eye movement

Proptosis

Decreased vision

Papilledema
This patient does not have proptosis. She has normal vision and normal extraocular movements, so periorbital cellulitis is more likely (Figure 1). Figure 1. Marked periorbital swelling with yellow discharge.
Core Knowledge Points – Differential Diagnosis
Conjunctivitis is generally not associated with the level of lid inflammation this patient has, so a more serious diagnosis must be considered.
Periorbital cellulitis (preseptal) is an inflammation of the eyelid and surrounding skin.
Orbital cellulitis (postseptal) is an inflammation posterior to the septum of the eyelid affecting the orbit and its contents.
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What are the physical findings that distinguish periorbital from orbital cellulitis?
Periorbital
Orbital
Fever
Fever
Lid warmth, edema, erythema, and tenderness
Lid warmth, edema, erythema, and tenderness
Red eye
Red eye
Conjunctivitis
Conjunctivitis

Chemosis

Periocular pain

Decreased extraocular eye movement

Proptosis

Decreased vision

Papillede

Because of the history of injury to the right eye area, a CT scan of the orbit is obtained. It reveals soft tissue swelling in the periorbital region extending medially beyond the orbital septum. It also reveals a fracture of the medial wall of the orbit anteriorly on the right with associated ethmoid and maxillary sinusitis.
The diagnosis, then, is right ethmoid and maxillary sinusitis (Figures 2 and 3) and periorbital cellulitis and medial intraorbital extraconal cellulitis without periosteal abscess (Figure 3).
Figure 2. Right maxillary sinusitis. Figure 3. Fracture of medial wall of orbit; ethmoid sinusitis; orbital cellulitis.

Core Knowledge Points – Diagnosis
Organisms that cause periorbital and orbital cellulitis are similar to those that cause sinusitis and those that can enter the skin or orbits as a result of trauma:
Staphylococcus aureus
Staphylococcus epidermidis
Streptococcus pneumoniae
Streptococcus sp.
Moraxella catarrhalis
Eikenella corrodens
Haemophilus influenzae (rare since introduction of vaccine)
Neisseria gonorrhoeae; Neisseria meningitidis; and Mycobacterium tuberculosis (unusual)
Often (35%) the cause is polymicrobial.
This patient’s history and physical findings have features common to both periorbital and orbital cellulitis. The mechanism of a fall or trauma to the skin around the eye is typical for patients with periorbital cellulitis, but it has been a reported cause of orbital cellulitis, especially with penetrating trauma to the orbit or as a result of fractures of the orbit.
In most cases, periorbital cellulitis results from trauma to the skin around the eye or from bacteremia.
Orbital cellulitis is most often caused by chronic sinusitis, with ethmoid sinusitis

Management – Diagnosis
The patient’s physical examination findings are most consistent with periorbital cellulitis: no decrease in EOM, no proptosis, no change in vision. The history of trauma, the severity of the periorbital swelling, and the elevated WBC count (14.4/mm3) and sedimentation rate (50 mm/h) are concerning enough to warrant a CT scan of the orbit. The decision to obtain diagnostic imaging is a difficult one. Some authors suggest that patients without clinical signs of orbital involvement (ophthalmoplegia, proptosis, or decreased visual acuity) can be managed initially with intravenous antibiotics. Beech and colleagues report that, of 34 patients with periorbital cellulitis, 14 had an elevated WBC count; seven of those patients ultimately required surgical intervention. None of the patients with a normal WBC count required surgery. These authors also note that patients who required surgery often had ophthalmoplegia, proptosis, or decreased visual acuity.
A CT scan of the orbits and paranasal sinuses is appropriate for patients who exhibit clinical signs of orbital cellulitis or its complications, and for those patients with periorbital cellulitis who do not respond to intravenous antibiotics or who develop complications. It is less clear whether CT imaging adds to the management of patients with elevated WBC counts and clinical evidence of periorbital cellulitis only.
The CT scan in this case reveals signs of early orbital cellulitis caused by the trauma to the orbit, which allowed for the development of sinusitis and its complications.
Case Development
The patient was treated with intravenous ceftriaxone, clindamycin, and vancomycin for 2 days, and her symptoms improved dramatically. Surgical intervention was not required.
She had no complications and was discharged with instructions to take clindamycin PO for 8 days.

Um comentário:

Pooja disse...

Pink eye is an infection or inflammation of the conjunctiva mostly because of some form of allergic reaction or infection. Bacterial and viral pinkeye are exceedingly transmittable. Allergic and chemical pink eye are non-contagious. There are many symptoms which include reddish eyes, eye lid inflammation, blurry eye sight, watery eye emission, eyelids get matted. For more details refer conjunctivitis
symptoms