Ocular and Periorbital Infections - Duke Pediatrics Intranet

Ocular and Periorbital InfectionsRavi Jhaveri M.D.Assistant Professor of PediatricsDuke Children’s Hospital

Objectives• Understand the clinical presentation,etiologic agents and treatment of:– Periorbital and Orbital Cellulitis– Conjunctivitis– Keratitis– Retinitis– Optic Neuritis

Periorbital and Orbital Cellulitis• Periorbital cellulitis-infection of softtissues anterior to orbital septum• Different from Orbital, which extendsposterior to the septum and threatens:– spread directly to sinuses of the brain andcause severe sequelae– loss of vision by thrombosis of retinal arteryor destruction/compression of optic nerve

Periorbital and Orbital Cellulitis• Pathophysiology-– Contiguous spread from infected sinuses mostcommon• Ethmoid sinusitis is a major contributor to Orbital Cellulitis– Breaks through the Lamina Papyracea– Direct inoculation via trauma of overlying skin and softtissue

A schematic illustrating the relationship between the eye and theparanasal sinusesWald, E. R. Pediatrics in Review 2004;25:312-320Copyright ©2004 American Academy of Pediatrics

Periorbital and Orbital Cellulitis• Usual agents-– Staph. Aureus and GABHS from skin– Strep pneumo from sinuses, also respiratory aerobes,other anaerobes• No specific data post-PCV7 to show that incidence hasdecreased, but I suspect that it has• No specific data that MRSA has increased incidence, butmaybe• Less common-• HSV-characteristic vesicles should be present• Fungus in immunosuppressed (Zygomycetes are deadly anddeforming!)

Periorbital and Orbital Cellulitis• Clinical manifestations:– Periorbital cellulitis usually associated with:• swelling of the eyelid• discoloration of the orbital skin, redness, andwarmth.• Conjunctival ecchymosis and injection withoccasional discharge, fever, and leukocytosis areseen.• Vision, extraocular movements, pupillaryfindings, and optometric examinations arenormal

Periorbital and Orbital Cellulitis• Orbital cellulitis tends to have similar butmore severe symptoms than preseptalcellulitis–Proptosis– decreased ocular mobility– ocular pain– tenderness on eye movement.

Periorbital and Orbital Cellulitis• Diagnosis:– Good history with attention to presentingsymptoms, risk factors in past medical history– PE must assess extraocular muscles and visualacuity-if the lid is swollen and you can’t see, callsomeone who can!!!– CT scan of orbit is test of choice-to assessinvolvement of orbital structures, presence of subperiostealabscess that needs drainage, R/O tumorif in doubt

Periorbital and Orbital Cellulitis• Treatment:– For Periorbital/Orbital cellulitis, few keys areparamount:• Prompt initiation of appropriate antimicrobial therapy-–2 nd /3 rd generation cephalosporin, +/- clindamycin,vancomycin are mostly likely choices» Need to worry about MRSA nowadays• Prompt referral for consultation of proper surgical service:ENT, Ophthalmology, Oculoplastics, whoever!– Surgery used to be mandatory, but that has changed• Frequent reassessment-if no surgery soon, maybe neededlater

Orbital Cellulitis outcomes• Nageswaran et al at Wake Forestreviewed 41 cases of Orbital Cellulitisover 10 years• Mean age 7.5 years• 40 children had ethmoid sinusitis• Conservative management performedwell, shorter stays than those to OR• Patients treated for 21 days withantibioticsNageswaran et al, PIDJ 2006 Aug;25(8):695-9.

Orbital Cellulitis outcomesNageswaran et al, PIDJ 2006 Aug;25(8):695-9.

Periorbital and Orbital Cellulitis• Keys to remember-– If symptoms are concerning, really need to checkvisual acuity and EOM to r/o orbital cellulitis– Prompt therapy will help prevent vision loss– Surgery may be needed at some point so transfer toget the appropriate team involved early

Conjunctivitis• Inflammation of the mucous membrane,which extends from lid margin to sulcus(palpebral) and sulcus to corneal limbus(bulbar)• Can be together or separate frominfections of cornea (keratitis)

• Symptoms include:Conjunctivitis– affect one or both eyes.– red, injected (hyperemic) conjunctiva– discharge that is watery or purulent– Matted eyelids are common.– Pseudomembranes may be present• they do not bleed when removed– True membranes as well• these are fibrin coagulated exudates attached toinflamed conjunctiva, which bleed if removed

Conjunctivitis• Bacterial agents to consider:– Gonococcal conjucitivitis• neonate in first 2-5 days after birth• Copious purulent discharge from the eye• Concerning for corneal ulceration withpermanent damage and systemic spread• Diagnosis by gram stain (GN2C) and culture• Patients need systemic antibiotics and copiousirrigation with monitoring of the cornea

Conjunctivitis• Bacterial agents to consider:– C. trachomatis– first two weeks, days 4-15– less discharge than GC, more watery withpseudomembrane– usually cough develops later– Therapy consists of topical and systemicantibiotics

Conjunctivitis• Bacterial agents to consider:– Other bacterial causes:• P. aeruginosa-preterm infants with bacteremia• H. influenzae– associated AOM 70-80% of the time• S. pneumoniae– Significant portion are non-typable (unencapsulated)• S. aureus• L. moncytogenes-farmyard dust, farmer’s eye• B. burgdorferi

Conjunctivitis• Viral agents to consider:– Adenovirus– Enterovirus/Coxsackievirus– Herpes Simplex– VZV/Zoster– Other viruses:• EBV• Influenza• Measles, Mumps, Rubella

Conjunctivitis• Adenovirus symptoms– Epidemic conjuctivitis or “Pink Eye”• Adenovirus 8,11,19• Progresses from unilateral to bilateral with 48h• Symptoms may include lid swelling,photophobia, foreign body sensation,conjunctival injection• Most contagious in first 7 days• Self limited in most cases• Ocular steroids may be used in chronic cases

Conjunctivitis• Adenovirus symptoms– Pharyngeal conjunctival fever, AKASwimming Pool Conjunctivitis• Adenovirus 3 or 7• Symptoms include non-purulent, follicularconjunctivitis• Also have pharyngitis, diarrhea, rash andlymphadenopathy• Self limited over 2-3 weeks• Symptomatic relief: artificial tears, coolcompresses

Conjunctivitis• Other entities to be familiar with:– Hemorrhagic conjunctivitis• Dramatic subconjuctivial hemorrhages– Herpetic blepharoconjucitivits• Can be seen in newborns between day 3-15 after birth• Classic HSV vesicles are present• May be associated with keratitis (more later)• Topical antivirals are usual therapy– VZV primary/zoster related conjunctivitis• Can have vesicles and ulcerations• Combinations of acyclovir and sometimes topical steroids(zoster)

Predicting Bacterial Conjunctivitis• Patel et al performed swabs on allchildren presenting with signs ofconjunctivitis• 111 patients over 1 year• Analyzed demographic andmicrobiologic data• 78% had bacterial etiology• Looked at symptoms that may bepredictive of bacterial etiologyPatel et al, Acad Emerg Med Volume 14, Number 1 1-5

Predicting Bacterial ConjunctivitisPatel et al, Acad Emerg Med Volume 14, Number 1 1-5

Patel et al, Acad Emerg MedVolume 14, Number 1 1-5

Outbreaks of S. pneumoniaeconjunctivitis• Outbreak inMinnesota amongschools anddaycares• Almost half of casewere S. pneumoniae• Serotyping showedthat these isolateslacked apolysaccharidecapsule

Diagnoses of Conjunctivitis in 698 Students at the Dartmouth College HealthService, According to the Date of the Clinic VisitMartin M et al. N Engl J Med 2003;348:1112-1121

Efficacy of Antibiotics forConjunctivits• Rose et al in England looked at treatingchildren with Chloramphenicol eye drops• Examined micro and clinical cure by 7days• 317 children from 6 months-12 yearsRose et al, Lancet. 2005 Jul 2-8;366(9479):37-43

Efficacy of Antibiotics forConjunctivitsRose et al, Lancet. 2005 Jul 2-8;366(9479):37-43

Rose et al, Lancet.2005 Jul 2-8;366(9479):37-43Efficacy of Antibiotics for Conjunctivits

Efficacy of Antibiotics forConjunctivits• Wald et al looked at topical vs. oralantibiotics to treat conjunctivitis andsubsequent AOM• Kids either received topical polymixinbactracin+ oral placebo vs. topicalplacebo + oral cefixime• Results: No difference in outcomes ofeither conjunctivitis or subsequent AOMratesWald et al, PIDJ 2001 Nov;20(11):1039-42

Activity of Ocular AntibioticsLevinson and Rutzen, Ophthalmol Clin N Am 18 (2005) 493 – 509

Run the Numbers• If you had 100 children with conjunctivitis– Approximately 80 would be bacterial• Of those kids, these agents wouldtheoretically cover this many cases:– Cipro/Oflox/Moxi/Chloro 80/80 (100%)– Polytrim 72/80 (90%)– Gent 63/80 (78%)

Ophthalmic Antibiotic Costs• GENTAMICIN 0.3% OPHTH SOLN– 5ML$11.99 15 ML $35.89• POLYTRIM OPHTH SOLN– 10 ML $41.99 30 ML $125.89• CHLOROPTIC OPHTH SOLN– 7.5ML$36.99 22.5 ML $110.89• OCUFLOX 0.3% OPHTH SOLN– 5ML $58.99 15 ML $176.89• CILOXAN 0.3% OPHTH SOLN– 5ML$65.99 15 ML $197.89• QUIXIN 0.5% OPHTH SOLN– 5ML$65.99 15 ML $197.89• VIGAMOX 0.5% OPHTH SOLN– 3ML $71.99 9 ML $215.89Walgreens.com 4/17/07

My take on Conjunctivitis• Most of the studies show that there is avery modest benefit with antibiotics• I know that everyone gets therapy because theycan’t go to school/daycare without it• There is almost no data to suggest there is amajor difference in pediatric bacterialconjunctivitis with the newer agents that aremuch more expensive– Polytrim is probably fine as 1 st line– Quinolones are also fine but more expensive– Chloramphenicol anyone?

Parinaud’s oculoglandularsyndrome• Spectrum of unilateral conjunctivitis withgranulomas, preauricular lymphadenopathyand external signs of inflammation aroundeye• Systemic symptoms include: fever, chills,malaise, anorexia or generalized LN• Causative agents include: B. henslae, F.tularensis, TB, Y. pseudotuberculosis• Most infections are self-limited, butantibiotics may accelerate resolution

Corneal Infections• Keratitis-symptoms include foreign bodysensation, eye pain, photophobia• On exam, cornea is opaque and willshow epithelial staining defect withfluorescein• May have hypopion-WBC in anterior chamber• Major risk factors for infection are:– Contact lens use– Post-procedure (LASIK, corneal transplant)– New meds for “chronic dry eye” (Restasis)

Corneal Infections• Classic bacterial pathogens:• P. aeruginosa• S. pneumoniae• S. aureus/S. epidemidis• P. acnes/Corynebacterium sp./Serratia/Nocardia• Others agents to consider:•TB• Syphilis• Treatment• Topical antibiotics in most cases• Appropriate systemic therapy for TB and syphilis

• HSV keratitisCorneal Infections– serious vision threatening condition– Usually reactivation via Trigeminal nerve– Vesicular rash may be present– Symptoms include pain, photophobia andblurred vision– On exam, classic dendritic lesions withfluorescein exam– HSV may spread to deeper eye tissues

Corneal Infections• HSV keratitis– Treatment includes:• Topical antivirals-trifluridine,acyclovir,vidarabine• Topical steroids• Systemic acyclovir for neonates and those withdeeper eye involvement» Some data to suggest need for more aggressivetherapy early in kids due to high complications– Recurrence rate is very high• 18% over 18 months after first episode• Suppressive oral acyclovir in those patients withprevious stromal disease/iritis cut recurrences by40% (32% vs. 19%) compared to placebo

Corneal Infections• Zoster keratitis/ophthalmicus– Zoster of ophthalmic branch of Trigeminal– Eye involvement is 50% when the tip of thenose is involved– “Pseudodendrites” on fluorescein exam• No terminal bulbs like HSV– Other findings are anterior uveitis andnummular keratitis– Treatment is topical antivrals• Cycloplegic agents if iris is involved

Internal Eye Infections• Endophthalmitis– Common organisms:• Streptococci/Staph species make up 2/3 ofinfections– Spread from endocarditis/GI source– Many patients with underlying medical diseases• Candida sp.– Seen in prematures/immunocompromised• Aspergillus– Seen in very immunocompromised

Internal Eye Infections• Endophthalmitis– Treatment consists of appropriate systemicagents– Surgical drainage/debridement may benecessary– Sometimes intravitreal anti-microbial agentsmay be needed

Internal Eye Infections• Uveitis– Inflammation of uveal tissues: vascularsubretinal choroid (posterior) and iris andciliary body (anterior)– Infectious causes tend to be classified intogranulomatous and non-granulomatous– May also involve other eye structures• Especially retinal structures

Internal Eye Infections• Uveitis– Infectious granulomatous types• Toxoplasmosis•Lymedisease•TB• Syphilis– Various non-ID causes– Sarcoidosis–MS

Internal Eye Infections• Uveitis– Infectious granulomatous types• Toxoplasmosis•Lymedisease•TB• Syphilis– Various non-ID causes– Sarcoidosis–MS

Internal Eye Infections• Optic Neuritis– Inflammation of optic nerve– Signs and symptoms include:– Vision loss– Loss of color vision– Visual field defect– Afferent pupillary defect– Most cases, etiology is never determined– Mean age: 10 years old– Unilateral 40%, Bilateral 60%

Internal Eye Infections• Optic Neuritis– On exam, optic disc is mildly swollen in66%– May be seen on fat-suppressed MRI– Therapies include IV steroids with oraltaper– New immunomodulatory agents areuntested– Subsequent development of MS in 20%

Internal Eye Infections• Optic Neuritis– Agents that have been shown to cause ON:•VZV•CMV•HIV•Lymedisease•TB• Toxoplasmosis• Toxocariasis

Internal Eye Infections• Neuroretinitis– ON with retinal involvement– Poor vision is main symptom– Retinal exam shows macular star– B. henslae is a well known cause ofneuroretinitis is children– Over 60% of these patients will have+IgG/IgM for B. henslae

• 10yr old female of French-Japanesedescent– 1 month of bitemporal HA worseningover last few days– fever up to 104F– Left eye pain and 4 ‘Black blobs’ seen inleft eyeCase and images courtesy Alan Shapiro, MD, PhD

Acute Retinal Necrosis• Features include necrotizing retinitis, vitritis,and retinal vasculitis often leading to retinaldetachment• Occurs in both healthy andimmunocompromised individuals• Approx. 1/3 have contralateral eyeinvolvement usually within 6 weeks of onsetof symptoms– Not always simultaneously– Longest interval reported is 34 years.

Clinical Features• Mild to moderate ocular pain may beworse with eye movements usuallyaccompanied by red eye• Blurred vision and floaters oroccaisionally reduced peripheral vision• Severe central visual loss is atypicalpresentation –posterior pole retinitis orretinal detachment occur later• Acute vision loss as a result of opticnerve involvement can occur.

Viral Causes of ARN

Internal Eye Infections• Retinitis-Other causes– CMV retinitis• Was common, now rare with HAART• “Cotton wool” spots are hallmark• Intravitreal ganciclovir/foscarnet– Toxoplasmosis• Seen in AIDS but also non-IC patients• Poor vision, leukokoria, floaters, disc edema• Treatment consists of any of the agents thattreat Toxo as well as topical or oral steroids

Internal Eye Infections• Retinitis-Other causes– Ocular Larval Migrans• Caused by Toxocara canis– Localized to the eye: Not VLM with systemic symptoms• Poor vision due to Inflammation/fibrosis ofchrioretinal areas, can spread to other structures• Treatment is albendazole and immunosuppresiveagents to control inflammatory response to deadlarvae

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