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You are seeing a 13 year old girl with 2 days of left eye redness and pain, and 1 day of fever. She recently got a new kitten and had been having itchy eyes and nasal congestion for the last 2 weeks. Her temperature is 38.3, HR 90, RR 20, BP 110/60, O2 sat 99% on room air. She is alert, has no nuchal rigidity, and is not toxic appearing. She has left periorbital edema and erythema but her eye can be manually opened. She is PERRL, has no chemosis or proptosis, and has mild conjunctival injection but no discharge. Her extraocular movements are full, but she complains of pain with extraocular movements. Her vision is 20/20 on the right and 20/60 on the left.
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June 9, 2020 at 11:13 pm
D) Admit for IV ceftriaxone and vancomycin and consultation with ophthalmologist from the ED
The patient is presenting with symptoms of orbital cellulitis, possibly from trauma while rubbing her eyes due to the kitten, but more often as an extension from sinusitis (kitten is a red herring). Concerning symptoms differentiating from pre-septal aka preorbital cellulitis would include proptosis, chemosis, pain on or limitation of extraocular movements, diplopia and vision impairment. This vignette is not consistent with mild conjunctivitis, which could be treated with topical ophthalmic antibiotics. A trial of outpatient therapy with oral antibiotics and close follow-up may be appropriate in mild pre-septal cellulitis, but not orbital cellulitis. Both vancomycin and a third-generation cephalosporin are needed to cover Staphylococcus, Streptococcus, and nontypable Haemophilus influenzae. The vision impairment is concerning, and an imaging study (typically CT in the ED) should be done urgently and ophthalmology consulted. Lateral canthotomy would only be warranted in the treatment of orbital compartment syndrome, manifestations of which include marked decrease in visual acuity, afferent pupillary defect, proptosis, diffuse subconjunctival hemorrhage, limited extraocular movements, chemosis, conjunctival injection, and evidence of increased intraocular pressure.