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PREORBITAL CELLULITIS

PREORBITAL CELLULITIS. The Case. AP 23/M Marikina Date of admission: July 23, 2011 Chief complaint: “pamamaga ng kanang mata”. History of Present Illness. 1 wk PTC 2-3mm raised, erythematous, tender, papule, right lower lid.

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PREORBITAL CELLULITIS

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  1. PREORBITAL CELLULITIS

  2. The Case • AP • 23/M • Marikina • Date of admission: July 23, 2011 • Chief complaint: “pamamaga ng kanang mata”

  3. History of Present Illness • 1 wk PTC • 2-3mm raised, erythematous, tender, papule, right lower lid. • After 11 hours  swelling of the lower lid with extension to lateral canthus • Pain (6/10, throbbing, localized), (+) tearing, (+) redness,(-) fever, (-) blurring of vision • No consult, no medications

  4. History of Present Illness • 3 days PTC • Fever (unknown degree) • Marked swelling, shut eye, increased tearing, pain (7/10, throbbing, right side of the face), (-) blurring of vision • Took Amoxicillin, no consult was made • Persistence of symptoms prompted consult

  5. Physical Examination • On the day of admission: • Conscious, coherent, not in CRD, stable V/S • VA: 20/20 OU • GE: Swelling of the right lower lid extending to the lateral canthus. No proptosis. (+) Redness, (+) Tearing, (+) Matted lashes, Pupils 2-3mm BRTL, (-) RAPD, narrow palpebral fissure • EOMs: Full OU • Digital palpation: Soft OU • Fundoscopy: +ROR, CM, DDM, 2:3 AV Ratio

  6. Laboratory • CBC • Elevated WBCs (11x 109/L) with neutrophilic predominance • Chest X-ray – unremarkable • Urinalysis, Na, K, Cl - unremarkable

  7. Primary Impression Preseptal Cellulitis OD

  8. Pre-Septal Cellulitis • Inflammation and infection of structures anterior to the orbital septum • Causes: • URTI – most common • Breaks in the skin • Antecedent events: Hordeola, Bug bites, Trauma, recent surgery • Pathogens: Staphylococcus Aureus/Epidermis, Streptococcus spp., Anaerobes

  9. Pre-Septal Cellulitis Orbital Septum • Fibrous tissue (thin) • Origin: Periosteum of orbital rims • Upper eyelid: up to levator aponeurosis • Lower eyelid: up to tarsal border • Barrier function

  10. Pre-septal Cellulitis: Presentation • Symptoms: • Pain • Swelling • Redness • Discharge • Conjunctival injection • Shut eye • Reduced vision (some) • Signs: • Periorbital erythema, induration, warmth, tenderness

  11. Pre-septal vs. Post-septal Pre Septal Post Septal Periorbital inflammation High morbidity, aggressive treatment, can be surgical Proptosis and chemosis Ophthalmoplegia and pain AbnormalVA, +RAPD • Periorbital inflammation • Less severe can be managed clinically • No proptosis • Normal eye movement • Normal VA, -RAPD

  12. Preseptal Cellulitis: Treatment • Management of predisposing conditions • Antibiotic Therapy • Mild: Amoxicillin/Clavulanic Acid, 1st gen Ceph, • If Staph infection suspected: Oxacillin/Nafcillin

  13. Course in the Wards • Day of admission • Patient placed on DAT • Hooked PNSS 1L x 8 hours • Administered Oxacillin 500mg IV q 6h • Vital signs and Neuro monitoring

  14. Course in the Wards • Day 2 • Conscious, coherent, not in CRD. Complains of pain (3/10, throbbing, localized to lower lid) • Stable V/S, 20/20 OU, swelling, redness, conjunctiva, shut eye, (+) Tearing(-) Proptosis, Full EOMs • Meds: Oxacillin 500mg IV q6h, with good compliance, no lapses • Continue VS and Neurologic monitoring

  15. Course in the Wards • Day 3 • Conscious, Coherent, not in CRD. Tenderness on palpation (2/10, localized to lower lid) • Stable V/S, 20/20 OU, swelling less than the previous day, (-) redness, narrow palpebral fissure,(+) Tearing (-) Proptosis, Full EOMs • Meds: Oxacillin 500mg IV q6h, with good compliance, no lapses • Incision and Drainage was done. Pus with blood x 2 OS partially soaked. Drainage was applied • Continue VS and Neurologic monitoring

  16. Course in the Wards • Day 4 • Conscious, Coherent, not in CRD. Tenderness on palpation (2/10, localized to lower lid) • Stable V/S, 20/20 OU, swelling less than the previous day, (-) redness, widening palpebral fissure,(+) Tearing (-) Proptosis, Full EOMs, soaked dressing • Meds: Oxacillin 500mg IV q6h, with good compliance, no lapses • Change of dressing was done, 1 OS minimally soaked • Continue VS and Neurologic monitoring

  17. Course in the Wards • Day 5 • Conscious, Coherent, not in CRD. Tenderness on palpation (2/10, localized to lower lid) • Stable V/S, 20/20 OU, swelling less than the previous day, (-) redness, wide palpebral fissure,(-) Tearing (-) Proptosis, Full EOMs, • Meds: Oxacillin 500mg IV q6h, with good compliance, no lapses • Dressing and drainage was removed • Continue VS and Neurologic monitoring

  18. Course in the Wards • Day 6 • Conscious, Coherent, not in CRD. No subjective complaints • Stable V/S, 20/20 OU, minimal swelling, (-) redness, wide palpebral fissure,(-) Tearing (-) Proptosis, Full EOMs, • Meds: Oxacillin 500mg IV q6h, with good compliance, no lapses, last dose given • Shifted to flucloxacillin 500mg q6h x 2 days • May go home

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