Hilary, 25, presents with 3 days of progressively swollen, painful red eye, on a background of recent “cold and flu” complicated by sinusitis. She has blurring of her vision and occasionally sees double. She has a fever and has felt “like Ive been run over by a truck” for the past few days.
What is the most likely diagnosis?
- Orbital Cellulitis
What are some differentials for this presentation?
- Orbital Cellulitis
- Pre-septal cellulitis
- Cavernous Sinus Thrombosis
- Allergic Conjunctivitis
- Viral conjunctivitis
- Angioedema
What are some important questions to ask Hilary about her recent health?
- upper respiratory tract infections
- sinusitis
- dental surgery
- prior surgery or trauma
- immune compromise
What are the key features of history you would inquire about to find a cause for Hilary’s symptoms?
- Massively swollen eye
- Red eye
- Visual disturbance
- Diplopia
- Blurry vision
- Fever
- Malaise
- Pain on eye movement
What are the key features of examination that would assist you in finding a cause for Hilary’s symptoms?
- Fever T > 37.5
- Severe Malaise
- Eyelid oedema (71% of people)
- signs limited to upper eye lid and not extending to brow
- Eye Erythema
- Chemoses
- Decr VA (14% of people)
- Proptosis ** (69% of people)
- Gaze restriction ** (59% of people)
- Diplopia (6% of people)
- Visual blurring
- Pain on eye movement (52% of people)
- RAPD (5% of people)
- Papilloedema / Neuritis
What are the key features of examination in pre-septal cellulitis?
- Fever
- Eyelid oedema – may extend to brow
- Erythema
- Chemoses
- Ptosis
- No Orbital signs
What are the key features of examination in Cavernous Sinus Thrombosis?
- fever
- headache
- mental status changes
- nuchal rigidity
- chemosis (red and bulging conjunctiva)
- proptosis
- impaired extraocular muscle motility, usually starting with lateral gaze
What is the most important initial management step to perform for Hilary?
- Immediate Referral to ED
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