Orbital Cellulitis

Effective management of orbital cellulitis in children requires a multidisciplinary team approach to ensure that patients receive prompt and effective treatment for this rare but potentially debilitating disease, according to a study presented at the 2013 Congress of the European Society of Ophthalmology. “Our study showed that we need to improve our compliance with diagnostic imaging and treatment guidance to effectively deal with orbital cellulitis in our paediatric patients,” Adam Bull, Stepping Hill Hospital, Stockport, UK, told delegates.

Dr Bull presented a retrospective review of diagnosis and antibiotic treatment options in a large district general hospital focusing on a 90-month period following the introduction of new orbital cellulitis guidelines. “The main features of these guidelines included the introduction of diagnostic criteria for performing CT scans, and also given the similar bioavailabilty between oral and intravenous preparations, the administration of oral antibiotics ciprofloxacin and clindamycin as first-line treatment to minimise delay,” he said. Dr Bull said it was important to try to distinguish the disease from the less severe preseptal cellulitis. “Whereas traditionally hallmark symptoms such as abnormal pupil reactions, pain associated with eye movement, double vision and proptosis have been used to distinguish orbital cellulitis from the milder preseptal cellulitis, this differentiation can be much more difficult in practice. The general consensus, therefore, is that if you cannot differentiate between the two, it is prudent to treat as orbital cellulitis,” he said. Differentiation is difficult Dr Bull’s joint study with Anna Maino FRCOphth, FEBO, included 40 children with an average age of six years, 32 of whom had been referred by their general practitioner, six by the emergency department and two by other hospitals. The most common findings were the presence of significant swelling encroaching on the visual axis, reduction in visual acuity which ranged from mild to severe loss and the presence of temperature at initial assessment. To determine the necessity or otherwise of performing a CT scan, the diagnostic guidelines are comprised of colour- coded criteria to help guide the treating physician, said Dr Bull.

“Our guidelines have orange and red criteria, which stipulate that if the patient has any of the orange criteria alone then this warrants discussion with a consultant to determine whether a diagnostic CT scan is indicated. If, however, a patient has any of the red criteria then this automatically fast-tracks them for emergency CT scanning,” he said. The review showed that while six patients had the orange criteria, none of these cases were discussed with the consultant with regards to whether a CT scan was warranted. A further six patients had red criteria and all were scanned within a 24-hour time frame. The review found that seven patients were diagnosed as preseptal cellulitis and were discharged. Of the remaining 33 patients, two were vomiting and therefore were not suitable for oral antibiotic therapy and were duly started on intravenous treatment. Oral antibiotics Of the initial total of 31 eligible patients, only nine received oral antibiotics as per the guidelines. The average time to treatment was 198 minutes in the intravenous group and 115 minutes in the oral group. Twenty-two patients who were suitable for oral antibiotic therapy were started on IVs, said Dr Bull. “We realise that we have to improve our compliance with diagnostic imaging and treatment guidance. To that end, we are disseminating the findings of our review both locally and internationally and have put on topic-specific training sessions for triage nurses and ophthalmic paediatric trainees,” he concluded.