Course outline Ocular and periocular infections Tina Rutar M.D. Assistant Professor, Department of Ophthalmology Department of Pediatrics University of California San Francisco Review basic anatomy of eye and orbit Review vision threatening signs Review orbital danger signs Infections Blepharitis Conjunctivitis Corneal infections Periorbital vs. orbital cellulitis Endophthalmitis Eye anatomy Eye anatomy www.thecountymedicalexaminers.com 1
Orbital anatomy Afferent pupillary defect www.wikidoc.org http://upload.wikimedia.org/wikipedia/ commons/8/8e/ Eye_orbit_anatomy_superior.jpg www2.aofoundation.org Afferent pupillary defect, patient video Vision-threatening signs Decreased visual acuity Afferent pupillary defect Opacity on the cornea Anything in the anterior chamber Absence of red reflex www.thecountymedicalexaminers.com 2
Decreased visual acuity Afferent pupillary defect Proptosis Limited motility Orbital danger signs Ocular and periocular infections Blepharitis Conjunctivitis Corneal infections Periorbital vs orbital cellulitis Endophthalmitis www.wikidoc.org Blepharitis Blepharitis Inflammation/infection of eyelid margins and Meibomian glands Staphylococcus aureus, Staphylococcus epidermidis, Propionibacterium acnes colonization and infection of eyelid margin Chronic burning, itching, irritation, dryness of eyes Eyes sticky, worse in the AM. Debris on lids and lashes Inspissation of Meibomian glands 3
4/27/12 Meibomitis http://www.contactlens.org.nz Hordeola (styes) http://www.mastereyeassociates.com Chalazia Treatment Hot compresses Eyelid hygiene Bacitracin ophth ointment to lashes bid x 10 days Artificial tears Meibomitis associated with rosacea: doxycycline PO or azithromycin PO Topical corticosteroid eye drops and ointments 4
Chalazia surgical treatment Ocular and periocular infections Blepharitis Conjunctivitis Corneal infections Periorbital vs orbital cellulitis Endophthalmitis Conjunctivitis,viral Red eye(s), discharge, sticky eyelids, mild itching, mild pain, foreign body sensation. Sick contact Begins in one eye, then goes to other eye Eyelid edema, conjunctival injection, conjunctival edema (chemosis), conjunctival follicular reaction, watery and mucous discharge. Preauricular node. Can last 2-3 weeks. Treat with: artificial tears, cold compresses, handwashing, contact precautions. 5
Conjunctivitis,viral Subtypes requiring additional treatments Adenovirus - occasionally topical steroids for corneal subepithelial infiltrates HSV conjunctivitis - oral acyclovir 200-400 mg PO five times daily or valacyclovir 500 mg PO bid-tid Recurrent VZV conjunctivitis oral acyclovir 800 mg PO five times daily or valacyclovir 1000 mg PO tid Molluscum contagiosum treated with incision, cautery, cryotherapy; if recurrent or multiple lesions, work up for immunocompromised state Conjunctivitis, bacterial Eye redness, foreign body sensation, copious discharge Conjunctival injection, conjunctival chemosis, purulent discharge Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pneumoniae, Haemophilus influenzae, Neisseria gonorrhoeae, Chlamydia trachomatis Treat with: topical antibiotic (polymyxin trimethoprim, ciprofloxacin) Systemic antibiotic for Neisseria gonorrhoeae (ceftriaxone IM/IV) and Chlamydia trachomatis (azithromycin PO/erythromycin PO) Cochrane review on antibiotic treatment of bacterial conjunctivitis Topical antibiotics compared to placebo are responsible for faster recovery clinically and microbiologically Most bacterial conjunctivitis is self limited, and it is not visually threatening 2/3 improved within 2-5 days in placebo arm No adverse events reported in either the antibiotic or placebo groups 6
Ocular and periocular infections Blepharitis Conjunctivitis Corneal infections Periorbital vs orbital cellulitis Endophthalmitis Distinguish conjunctivitis from keratitis http://www.optometric.com/archive Causes of keratitis Infectious keratitis: bacterial, fungal, viral, acanthamoeba. Many noninfectious causes of keratitis. Risk factors for infectious keratitis: Decreased corneal sensation: diabetes, CN5 palsy, herpes infection Overnight contact lens wear and poor contact lens hygiene Corneal abrasions/trauma Prior eye or eyelid surgery Poor eyelid closure 7
Bacterial corneal ulcer Bacterial corneal ulcer Infection of the corneal stroma (overlying epithelial defect) Diagnosis: corneal Gm stain and culture Highly virulent organisms: Pseudomonas, Streptococcus pneumoniae, gonococcus Treatment: hourly broad-spectrum antibiotic (moxifloxacin or gatifloxacin) or fortified topical antibiotics (vancomycin + tobramycin or gentamycin) discontinue contact lens wear Ocular and periocular infections Periorbital cellulitis Blepharitis Conjunctivitis Corneal infections Periorbital vs orbital cellulitis Endophthalmitis 8
Periorbital cellulitis Periorbital cellulitis http://meded.ucsd.edu/clinicalimg Periorbital cellulitis Orbital cellulitis Infection that is anterior to the orbital septum involving the periorbital soft tissue and the eyelids Edema, erythema, tenderness affecting eyelids/periorbita Quiet eye (noninjected conjunctiva) Associated sinusitis, hordeolum, violation of the skin Treatment PO antibiotics: no fever, age >1 year Oral clindamycin or trimethoprim/sulfamethoxazole in community MRSAprevalent area Oral cephalexin with close follow up if low likelihood of MRSA, mild infection IV antibiotics: fever, elevated WBC/neutrophil count, infant, worsening 9
Orbital cellulitis Orbital cellulitis An infection posterior to the orbital septum with involvement of orbital structures (can affect extraocular muscles, sensory and motor nerves and the optic nerve ) Decreased vision Afferent pupillary defect Proptosis Limited motility, pain w motility, diplopia Conjunctival injection/chemosis Associated sinusitis, bacteremia, antecedent periorbital cellulitis, dental infection Treatment and work up Hospital admission IV antibiotics (vancomycin + piperacillin/tazobactam) Blood cultures, cultures of orbital abscess or sinuses Orbital imaging (orbital/sinus CT with contrast) Surgery (drainage of orbital abscess, sinus drainage) Ocular and periocular infections Blepharitis Conjunctivitis Corneal infections Periorbital vs orbital cellulitis Endophthalmitis Endophthalmitis Infection involving the vitreous cavity (+other parts of the eye) Pain, decreased vision, conjunctival injection, hypopyon, poor red reflex 10
4/27/12 Endophthalmitis, post trauma Endophthalmitis, post surgical Scott and Flynn. http://www.retinalphysician.com Endophthalmitis, endogenous Bacterial endopthalmitis management/treatment Vitreous culture (anterior chamber culture) Intravitreal injection(s) of antibiotics (vancomycin + ceftazidime if organism unknown), and occasionally steroids Vitrectomy surgery (occasionally) Intravenous antibiotics Endogenous endophthalmitis Post traumatic endophthalmitis Not generally used for post surgical endophthalmitis If endogenous, blood culture(s) and work-up for source of infection 11
When to refer ocular and periocular infections to ophthalmology Vision threatening signs Decreased visual acuity Afferent pupillary defect Opacity on the cornea Anything in the anterior chamber Absence of red reflex Orbital danger signs Decreased visual acuity Afferent pupillary defect Proptosis Limited motility History of prior eye surgery 12