CONDITION GUIDELINE

Orbital cellulitis Causes

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Spread of infection from neighbouring structures, e.g. nasal sinus;

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Sepsis following penetrating injuries;

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Following septic operations, e.g. enucleation;

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Facial erysipelas;

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Spread of pyaemia – causative organisms: pneumococcus;Staphy- lococcus; Streptococcus.

Signs

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Proptosis of the affected eye, pushed forward by the inflamed tissue within the orbit, behind the eyeball;

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Red and inflamed lids;

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Chemosis of conjunctiva;

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Formation of abscess over the upper eyelid;

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Reduction in visual acuity;

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Reduction in colour vision;

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Malaise and fever;

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Relative afferent pupil defect;

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Possible double vision;

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Limitations and painful ocular movements;

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Possible signs of optic nerve dysfunction in advanced cases.

Patient’s needs

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Admission to hospital if necessary.

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All suspected cases of orbital cellulitis will need to have a CT scan to look for any sight/life-threatening subperiosteal and orbital collec- tions. The scan will also show evidence of any adjacent sinus disease.

If adjacent sinus disease is not located but intraconal opacity is seen on the CT scan, trauma or foreign body should be suspected.

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Relief of symptoms:

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Pain – especially on eye movement;

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Nasal congestion;

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Fever – there may be rigors;

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Anorexia;

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General malaise.

Nursing action

1 Admit patient to ward if necessary.

2 Arrange urgent CT scan of paranasal sinuses orbits and brain.

3 Arrange urgent referral to ear, nose and throat specialist.

4 Take bloods for full blood count, urea, electrolytes and glucose.

5 It is important to liaise with microbiologist, especially if local changes in sensitivity and resistance occur.

6 Give prescribed analgesia for pain. Local heat application may be comforting.

7 Fan and/or tepid sponge patient to bring down temperature.

8 Administer prescribed antibiotics:

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Oral, e.g. clindamycin which is effective against Gram-positive cocci such as streptococci, dose for adults 150–300 mg 6 hourly and, where the infection is severe, 450 mg 6 hourly. Child doses are calculated based on 3–6 mg per kg of bodyweight 6 hourly and Ciprofloxacin 500–750 mg BD for adults (British National Formulary, 2009). Oral antibiotics may be continued for up to 6 weeks.

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Eyedrops, e.g. G. chloramphenicol 0.5%, to be given 2–4 hourly.

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In severe cases, intravenous antibiotics may be prescribed.

9 Administer nasal decongestant spray as prescribed e.g. xylometa- zoline hydrochloride 0.1%.

10 Give nourishing fluids and a light diet.

11 Provide general nursing care of an ill patient.

12 Dress abscess if this forms.

13 Prepare for, and give, post-operative care of patient following drainage of abscess sinuses. Send any pus from drainage for analysis.

14 Monitoring of optic nerve function hourly or as directed by the doctor–testing distance visual acuity, pupillary reactions, assess- ing colour vision using the Ishihara colour vision chart and light brightness appreciation (Kanski et al., 1996).

15 Prolapsed conjunctiva requires a Frost suture and lubricants.

Complications

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The infection may spread backwards into the brain causing:

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Cavernous sinus thrombosis;

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Meningitis;

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Brain abscess.

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Possible occurrence of panophthalmitis;

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Sinus formation, if the cause is a sinusitis;

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Optic atrophy due to pressure on the nerve;

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Subperiorbital abscess;

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Central retinal vein or artery occlusion;

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Raised intra-ocular pressure;

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Exposure keratopathy.

Where orbital cellulitis occurs in a child, referral to an ear, nose and throat specialist is usual, as the cause is invariably from ethmoidal/

maxillary sinus.

Preseptal cellulitis

Preseptal cellulitis is infection of the eyelids only, i.e. preseptal. Preseptal cellulitis is often preceded by infection of the teeth or sinuses, by trauma or by infected lid chalazion (inflammatory cyst). The infection does not spread beyond the orbital septum of the upper lid into the orbit. The signs and symptoms are similar to orbital cellulitis, but the condition is not so dangerous.

If a child presents with an obvious lid cyst, treat with oral antibiotics and consider drainage. The child must be reviewed daily until improvement is seen.

The child is to be admitted if unwell, if in pain, if it is due to trauma, if no clear history, if parental understanding is poor or if significant ptosis is obstructing examination.

Cavernous sinus thrombosis

The cavernous sinus is situated near the pituitary gland. Through it pass many of the veins draining structures around the face, including the orbit, globe, nose, mouth, sinuses and the meninges. Thus infection can spread from any of these structures into the cavernous sinus. It may also spread from a general infectious disease or septic focus elsewhere in the body. It is a serious condition. Fifty percent of cases are bilateral.

CONDITION GUIDELINE

Cavernous sinus thrombosis

Signs

Signs are as for orbital cellulitis, plus some others:

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Paralysis of the extra-ocular muscles, as their nerves pass through the cavernous sinus and are thus involved;

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Dilated pupil(s), usually non-reactive due to the trigeminal nerve being involved as it also passes through the cavernous sinus;

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Anaesthetic cornea due to the involvement of the trigeminal nerve;

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Reduced visual acuity due to pressure;

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Papilloedema due to pressure;

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Signs of cerebral irritation may also be present.

Patient’s needs and nursing action

1 Patient’s needs and nursing action are as for orbital cellulitis.

2 The antibiotics will be administered by the intravenous route in large doses.

3 Anticoagulants may be prescribed.

Thyrotoxic exophthalmos

Graves’ disease describes the most common cause of hyperthyroidism and is thought to be due to an autoimmune problem. It usually affects women be- tween the ages of 20 and 45 years who have signs and symptoms of thyrotox- icosis together with ophthalmic signs. Ophthalmic signs can occur in patients who are clinically euthyroid and, in these cases, the disease is referred to as ophthalmic Graves’ disease. The signs and symptoms tend to be similar.

CONDITION GUIDELINE

Thyrotoxic exophthalmos Signs

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Exophthalmos – unilateral or bilateral. Inflammatory exudates and plasma cell infiltration of the orbital fat and extra-ocular muscles push the globe forwards (Figure 6.5).

Figure 6.5 Bilateral proptosis. From Olver and Cassidy (2005), Ophthalmology at a Glance, Blackwell Publishing, reproduced with permission.

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Lid lag – when looking downwards, the top lid normally moves with the eye. In this condition, the lid moves very slowly down or not at all.

This is possibly due to sympathetic overactivity of M¨uller’s muscle.

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Lid retraction – the upper lid retracts, giving the typical ‘stare’ as- sociated with thyroid eye disease. The sclera above the cornea is visible. This is probably due to involvement of the levator muscle.

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Corneal exposure – corneal exposure occurs because:

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The lids are unable to close over the protruding globe.

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Defective blinking occurs because of involvement of the lid muscles.

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Exophthalmoplegia – this is the inability to move the eye in the fields of gaze because the extra-ocular muscles are involved due to infiltration and later fibrosis. Diplopia results.

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In hyperthyroidism, signs of thyrotoxicosis such as tachycardia and muscular tremors may be present.

Patient’s needs

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Protection of the exposed cornea – which is the most important factor;

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Prevention of complications, which can result in loss of vision;

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Investigation and treatment of thyroid state by an endocrinologist;

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Correction of diplopia;

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Treatment of lid lag;

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In severe cases, rapid relief of orbital pressure;

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Psychological care – the patient may be frightened and in need of reassurance.

Nursing action

1 Corneal exposure – the nurse will:

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Instruct the patient in application of prescribed ointment such as simple eye ointment or Oc. chloramphenicol 1% at night.

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Prepare the patient for a tarsorrhaphy, which may be necessary;

the edges of the eyelids are sewn together, usually in the lateral aspect, to protect the cornea.

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Instruct the patient in the use and care of a bandage contact lens;

this is a large contact lens which covers the whole of the cornea, thereby giving protection (see Appendix 2: Contact Lenses).

2 Explain the investigations needed for thyroid function estimations.

3 Explain to the patient that diplopia can be treated by wearing glasses with prisms in the lenses. A squint operation may be carried out when the thyroid state is stable.

4 Treatment for lid lag – the nurse will prepare the patient for lid surgery when M¨uller’s muscle will be divided.

5 In severe cases, where emergency treatment is required to reduce the orbital pressure, the nurse will:

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Give the prescribed high doses of systemic steroids.

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Prepare the patient for orbital decompression – part of the lateral wall of the orbit is removed so the orbital contents can prolapse and therefore relieve the pressure on the optic nerve.

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Prepare the patient for radiotherapy.

Complications

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Corneal ulceration due to exposure keratitis;

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Visual loss due to optic nerve compression, central retinal artery and vein occlusion;

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Cataract formation due to metabolic disturbance to the lens;

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Secondary glaucoma due to compression on the globe by the orbital contents, causing the intra-ocular pressure to rise.