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Ocular and periocular infections

Tina Rutar M.D. Assistant Professor,

Department of Ophthalmology Department of Pediatrics

University of California San Francisco

Course outline

•  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

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Eye anatomy

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Orbital anatomy

www.wikidoc.org http://upload.wikimedia.org/wikipedia/commons/8/8e/Eye_orbit_anatomy_superior.jpg

Afferent pupillary defect

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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

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Orbital danger signs

•  Decreased visual acuity

•  Afferent pupillary defect

•  Proptosis •  Limited motility

www.wikidoc.org

Ocular and periocular infections

•  Blepharitis •  Conjunctivitis •  Corneal infections •  Periorbital vs orbital cellulitis •  Endophthalmitis

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

Blepharitis

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Meibomitis

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Hordeola (styes)

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

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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.

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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

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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

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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

•  Blepharitis •  Conjunctivitis •  Corneal infections •  Periorbital vs orbital cellulitis •  Endophthalmitis

Periorbital cellulitis

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Periorbital cellulitis Periorbital cellulitis

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Periorbital 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 MRSA-

prevalent area •  Oral cephalexin with close follow up if low likelihood of MRSA, mild infection

–  IV antibiotics: fever, elevated WBC/neutrophil count, infant, worsening

Orbital cellulitis

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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

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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

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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