FIGURE 123.5 CT scan of a child with right-sided orbital cellulitis demonstrating retro-orbital inflammation and a subperiosteal abscess Diagnostic Testing Imaging is not routinely indicated in periorbital cellulitis In patients with concern for orbital cellulitis, CT or MRI scanning is used to confirm the diagnosis and detect its complications including subperiosteal abscess, orbital abscess, cavernous sinus thrombosis, and/or brain abscess An MRI spares the patient radiation exposure and can readily identify orbital disease that can mimic orbital cellulitis such as tumor, hemorrhage, or inflammatory pseudotumor CT imaging however is cheaper, more readily available, less likely to require sedation, and affords excellent views of the bony orbital wall ( Fig 123.5 ) Contrast-enhanced imaging should generally be expedited in all cases with highrisk features including limitation or pain with eye movements, vision loss, proptosis, signs of CNS involvement, inability to perform a reliable examination, and cases of presumed periorbital cellulitis which not improve on IV antibiotics within 48 hours Management and Disposition In otherwise well children who are beyond infancy and have mild periorbital cellulitis and no systemic signs or symptoms, oral antibiotics are appropriate The prognosis for complete recovery without complications is excellent The patient should be reevaluated within 24 to 48 hours to ensure improvement If no improvement occurs, the patient should then be admitted for IV antibiotics All cases of suspected orbital cellulitis should be promptly hospitalized and treated with IV antibiotics Recent studies confirm that in the absence of acute visual compromise or other signs of disease progression, even children with small or moderate-sized abscesses deserve a trial of medical therapy before surgical intervention Empiric broad-spectrum antibiotic treatment should be directed toward known common pathogens, including skin flora when local trauma is the likely etiology, and upper respiratory flora in cases of presumed underlying sinus disease Appropriate empiric regimens should include coverage for S aureus (including MRSA if unwell or risk factors are present), streptococci, and gramnegative bacilli Anaerobic coverage should be added for cases associated with sinusitis, an odontogenic source, or proven or suspected intracranial extension The yield of blood cultures post Hib vaccine is very low, however blood cultures should be considered before initiating IV antibiotic therapy Percutaneous aspiration from the area of cellulitis is not recommended Other systemic cultures (e.g., cerebrospinal fluid) may be indicated if signs of systemic toxicity or findings of CNS disease are present The patient should be reevaluated daily looking for signs of improvement Ophthalmic consultation and evaluation is recommended for all pediatric patients with orbital cellulitis Otorhinolaryngology consultation should also be considered in those with associated sinusitis Neurosurgical consultation is needed for those with intracranial extension Conjunctivitis CLINICAL PEARLS AND PITFALLS Not all cases of “red eye” are due to conjunctivitis Gonorrhea should be suspected in a neonate with purulent conjunctivitis Antimicrobial therapy is not indicated for cases of viral conjunctivitis Contact lens wearers with conjunctivitis are at risk for keratitis and should remove their contact lens and be evaluated by an ophthalmologist Steroid drops should not be prescribed by the ED clinician Current Evidence The conjunctiva is the mucous membrane that lines the inner surface of the eyelids and reflects back to cover the surface of the globe up until the cornea Conjunctivitis refers to “inflammation of the conjunctiva” and it is the most common acute eye disorder seen by pediatric ED clinicians Acute conjunctivitis is generally classified as either infectious or noninfectious Infectious conjunctivitis may be bacterial or viral Bacterial conjunctivitis in children is commonly caused by Streptococcus pneumoniae, H influenzae, S aureus, and Moraxella catarrhalis N gonorrhea can be a causative agent in sexually active adolescents Viral conjunctivitis is typically caused by adenovirus, although enteroviruses and herpes simplex virus (HSV) are also possible pathogens Noninfectious conjunctivitis includes both allergic conjunctivitis from airborne allergens (which may manifest as acute hypersensitivity reactions or more gradual seasonal reactions) and nonallergic conjunctivitis resulting from a mechanical or chemical insult Goals of Treatment Acute conjunctivitis is typically a benign self-limited disease but can cause significant patient discomfort Goals of treatment include symptomatic relief and shortening of the clinical course when possible Eye lubricants (artificial tears) and/or cool compresses may provide symptomatic relief in all cases Topical antibiotics may be used for bacterial conjunctivitis to hasten healing time and eradicate the pathogen Cases with atypical courses and those that not respond to treatment as expected should be referred to an ophthalmologist for further evaluation Clinical Considerations Clinical Recognition The hallmark of conjunctivitis is dilation of conjunctival blood vessels resulting in erythema and edema Common symptoms include eye redness, irritation, tearing, discharge, and morning crusting The patient’s age is often useful in determining a specific diagnosis Almost all newborn nurseries now use erythromycin ointment or dilute betadine solutions for prophylaxis against gonorrhea However, no prophylaxis is completely effective An infection with gonorrhea typically presents to days after birth with sudden onset, severe, grossly purulent conjunctivitis, with profuse exudate and swelling of the eyelids ( Fig 123.6 ) Left untreated it can rapidly progress to corneal ulceration and perforation Neonatal chlamydia trachomatis conjunctivitis, also known as inclusion conjunctivitis of the newborn (ICN), typically presents to 14 days after delivery and can range from mild swelling with a watery to mucopurulent discharge, to marked swelling of the eyelids with red, thickened, and friable conjunctivae Untreated infection can cause corneal and conjunctival scarring These two forms of conjunctivitis, as well as other forms of bacterial conjunctivitis (S aureus, Escherichia coli , Pseudomonas aeruginosa ), can be difficult to distinguish clinically and may coexist FIGURE 123.6 Neonatal gonorrheal conjunctivitis Note the dramatic lid swelling and severe purulent discharge In children beyond the neonatal period, a wide range of organisms, both viral and bacterial, as well as chlamydia, can cause conjunctivitis Clinically, these entities may be indistinguishable Table 123.1 is designed to give some additional help in differentiating causes of conjunctivitis In general, purulence is more characteristic of bacterial infections, whereas clear serous discharge is more characteristic of viral infection Bacterial and viral conjunctivitis can be associated with otitis media and pharyngitis, respectively Although both viral and bacterial conjunctivitis may be unilateral or bilateral, a history of multiple infected contacts, or consecutive involvement of one eye and then the other, argues in favor of a viral etiology Likewise, dramatic lid swelling associated with preauricular adenopathy, mucoid or serous discharge, and perhaps an uncomfortable, sandy, foreign-body sensation is strongly suggestive of epidemic keratoconjunctivitis secondary to adenovirus This fulminant viral infection is usually easy to recognize ( Fig 123.7 ) Both HSV and varicella zoster virus can cause infections limited to the skin surrounding the eye ( Fig 123.8 ) or may also involve the cornea and/or conjunctiva Patients with ocular HSV infection usually ... looking for signs of improvement Ophthalmic consultation and evaluation is recommended for all pediatric patients with orbital cellulitis Otorhinolaryngology consultation should also be considered... refers to “inflammation of the conjunctiva” and it is the most common acute eye disorder seen by pediatric ED clinicians Acute conjunctivitis is generally classified as either infectious or noninfectious