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Morning Report

Morning Report. Gaby Paskin 7/2/13. JM. 5 year old female comes to the ER with pain and swelling of left eye for 1 day Punched in the eye by her 3 year old brother yesterday Yesterday developed photophobia, and mom patched her eye

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Morning Report

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  1. Morning Report Gaby Paskin 7/2/13

  2. JM • 5 year old female comes to the ER with pain and swelling of left eye for 1 day • Punched in the eye by her 3 year old brother yesterday • Yesterday developed photophobia, and mom patched her eye • This morning, increased swelling, pain, unable to open eye, so came to ED

  3. JM continued • No fevers, no LOC, no dizziness, no nausea/vomiting, no discharge from eye • +mildly blurred vision • Refusing to open left eye • In ED, febrile to 102.7 • On exam: significant swelling of upper and lower eyelid, + tenderness to palpation, mild ptosis, +decreased lateral movement of eye

  4. JM continued • WBC: 32.1 • Hg/Hct: 14.7/40.8 • Plt: 441 • CT: mildly depressed fracture of left lamina papyracea with adjacent sinus opacification and inflitration of intraorbital fat

  5. DDX • Orbital cellulitis • Preseptalcellulitis • Trauma • Bites • Allergic reaction • Hordeolum • Conjunctivitis • Mucocele • Graves disease • Tumor

  6. Orbital/pre-orbital celluitis • Orbital cellulitis: infection involving the content of the orbit (fat and ocular muscles) • Preorbital/preseptalcellulitis: infection of anterior portion of eyelid • Neither involves infection of the globe

  7. Preseptalcellulitis • Infections of the soft tissues anterior to the orbital septum • Rarely leads to serious complications • More common in children than adults • Causes: often external sources, not sinuses • Local trauma: bites • Foreign bodies • Staphaureus, strep pneumo, other streps, anaerobes, MRSA

  8. Preseptalcellulitis continued • Clinical manifestations • Ocular pain • Eyelid swelling • Erythema • Rarely chemosis in severe cases • Diagnosis • History and physical • Imaging • CT orbit/sinuses

  9. Treatment • Children > 1 year and mild preseptalcellulitis, no systemic toxicity: treat as outpatient • < 1 year, cannot cooperate for full exam,orseverely ill: admit and manage according to orbital cellulitis recommendations • PO antibiotics: Clindamycin or Bactrim + amox, Augmentin, Cefpdoxime, cefdinir, 7-10 days • Fail to show improvement in 24 hours should be hospitalized for IV antibiotics

  10. Orbital Cellulitis • Infections posterior to the orbital septum • More common in young children than older children and adults • Rhinosinusitis is most common cause of orbital cellulitis • Uncommon complication • Usually from ethmoid sinusitis or parasinusitis • Other causes: ophthtalmicsurgery, ocular trauma, dacryocystitis, infection of teeth, face or middle ear

  11. Orbital cellulitis continued • Micro • Usually Staph and strep • Rarely can be fungi or mycobacteria • Clinical manifestations • Ocular pain • Eyelid swelling • Erythema • Pain with eye movements • Proptosis • Ophthalmoplegia • Chemosis • Visual impairment (inflammation or ischemia of optic nerve)

  12. Complications • Subperiosteal abscess • 15-59% of cases • Sometimes requires surgery • Orbital abscess • Up to 24% • More severe symptoms • Vision loss • 3-11% • Secondary to optic neuritis, ischemia, increased pressure • Cavernous sinus thrombophlebitis • Central retinal artery occlusion • Brain abscess

  13. Diagnosis • Exam • Ophthalmoplegia, pain with eye movement, proptosis, chemosis • Consult ophtho • Imaging • CT or MRI • MRV if concern for thrombosis • Indication to image: proptosis, limitations of eye movement, pain with eye movement, diplopia, vision loss, edema extending beyond eyelid margin, ANC > 10,000, signs or symptoms of CNS involvement, inability to examine the patient fully (<1 yo), patients who do not begin to show improvement with in 24-48 hours of initiating appropriate therapy

  14. Treatment • Broad spectrum antibiotics: to cover S. aureus, strep and gram-negative bacilli • Vanco and ceftriaxone, cefotaxime, Unasyn or Zosyn • If suspected intracranial extension, also cover for anaerobes (metronidazole) • Should show improvement within 24-48 hours • Oral medications when afebrile and findings have started to resolve • Surgery if unresponsive, large abscess, worsening vision changes

  15. Question 1 • A 4 year old boy presents with a 40day histpry of worsening right eyelid swelling and redness aftera mosquito bite. On physical exam, his temperature is 38.0, HR 100, RR 25. His right eyelid is markedly swollen, red and tender, andhe is unable to open it fully. His conjunctivae are clear, and extraocular movements are not limited. There is no proptosis. Visual acuity is difficult to assess fully but appears normal. There are no other physical findings or note. The WBC is 19 with 55% PMN, 20% bands, 20% lymphocytes, and 5% monocyte. • Of the following, the MOST appropriate antibiotic for this patient is • Ampicillin-sulbactam • Cefazolin • Clindamycin • Doxycycline • Trimethoprim-sulfamethoxazole

  16. Question 2 • A 14 year old softball player comes to the emergency department after being struck in the eye by a pitch. She is awake, and alert, complaining of right eye and face pain. She has obvious swelling and ecchymosis around her right orbit. Her extraocular movements are normal on the left, but she is unable to look up with her right eye. Her globe is intact, vision is 20/20 in both eyes and pupils are equally round and reactive; no corneal injuries are apparent on fluoresecin examination. • Of the following, the injury that BEST explains this girl’s physical findings is • Epidural hematomoa • Intracranial contusion • LeFort fracture, type 1 • Right orbital floor fracture • Right temporal skull fracture

  17. Question 3 • A 2 year old boy presents to your office with a 2-day history of swelling of the right eye. He has been otherwise well. There are scattered insect bites on his body, including one about 2 cm lateral to the affected eye. There is no discharge, and the bite appears to be healing. The boy’s right eyelids are swollen and seem tender to palpation. • Of the following, the MOST concerning additional ophthalmologic finding for this boy is • Decreased extraocular movements • Hyperemia of the palpebralconjuctiva • Photophobia • Purulent exudates • Subconjunctivalhemorrahges

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