00:00
In this lecture, we're going to discuss Orbital Cellulitis and Preseptal Cellulitis. Basically, a child
who comes in with an infected red eye. It's important to distinguish between these 2 things
because we treat them differently. Bear with me here. Imagine if you will a bunch of firefighters
around one of those old trampolines and they're underneath the building and they're screaming
"jump, jump" to the poor person who is up on the third floor who they want to save. Let's think
about that trampoline they're holding and let's imagine that we have this trampoline but that
center spot where the red dot is, we cut it out so there's a little hole. So here is that trampoline
with the little hole in it. Now let's drop a ball into the hole but the ball is bigger than the hole
so it sits in place. There's the ball. This is essentially the eye, the ball is the eyeball and the
green part is the septum and that septum is holding the eye in place just like that ball is being
held up. So here's a side view of an eyeball. That ocular septum, the orbital septum is coming down
and around the eye and there's an extension so that that eye is firmly held into the head.
01:26
However, that septum serves more than just a structural role. It prevents bacteria from growing
in 1 direction or the other. So infections in front of the septum will be different than the ones
behind the septum. That septum is acting as a physical structure that holds the eye in place but
also a barrier for infectious organisms. So if we look at this eye again, infections outside the
eye we call preseptal or before the septum cellulitis. These infections are mostly from the skin
and the number one organisms are <i>Staph</i> and group A <i>Strep</i>. However, if an infection is here behind
the septum, this is orbital cellulitis and these infections don't come from the skin most commonly
most commonly they come from the sinuses because the sinus is a paper-thin wall away from
the orbit. So, let's look then at the differences between these 2 infections. Orbital cellulitis is a
mixed floral infection from the sinuses. It includes gram positives, gram negatives and even
anaerobes and it requires broad-spectrum antibiotics to kill those bacteria. Also, there is a
vision risk. This is an emergency. Preseptal cellulitis is usually group A <i>Strep</i>. We usually can
treat it with narrow-spectrum antibiotics like a first generation cephalosporin and it rarely
spreads into the eye if we treat it correctly. So, this 18-month-old is coming in to see you and
he has a swollen eye. How do I tell if it's preseptal cellulitis and I require only a narrow-spectrum
first generation cephalosporin or it's a postseptal infection called orbital cellulitis and any
broad-spectrum antibiotics and I have to worry about this patient? How do I tell the difference?
Well, there are number of ways we can tell the difference and here's all the symptoms and whether
it's likely in preseptal or orbital. Orbital cellulitis can present with just about everything but
preseptal cellulitis, it's a little clearer. Let's look at these in 2 groups. In preseptal cellulitis,
patients will have eyelid swelling, redness and discharge. They can have that also in orbital
cellulitis and they will have a normal pupillary response which is usually the case in orbital cellulitis
but certainly if you see an abnormal pupillary response you should worry about that patient
but preseptal cellulitis does not present with diplopia, with abnormal eye movements, with pain
with eye movements, or with proptosis. If you see any of these things, you should presume
this is orbital cellulitis. So, let's talk a little bit about diplopia. We need to understand where these
sinuses are and why these patients with orbital cellulitis but not preseptal cellulitis get diplopia
and pain with eye movements. So here's a little child who's presenting with a red eye and this
child has an infection of their ethmoid sinus. Remember that ethmoid sinus is just medial to the
eye, which means that when that infection broke through that paper-thin bone, it entrapped
the medial rectus muscle of this patient's eye. So now we'll ask this patient to look around.
05:01
I asked them to look to the side towards their affected ethmoid sinus, they should be doing
okay but when I asked them to look away from the infected sinus, that infected medial rectus
muscle is entrapped. They can't look out. So if I see a patient who looks like this, I can say very
comfortably this is probably an orbital cellulitis and I'll bet you it's from an ethmoid sinusitis.
05:32
Now, here's a little boy coming to see us. He has also got a red eye but this little boy has infection
of his maxillary sinuses. So now this infection is going to escape upward into the inferior rectus
muscle just below the eye. Let's have this boy look around. He can look to the left. Right? He
can look to the other side. Right? He's doing okay with lateral movement. When we asked him
to look down, he's fine but when we asked him to look up his inferior rectus muscle is entrapped
and he has a dysconjugate gaze. It hurts for him to look up and you can see that his eye doesn't
want to go that way.