Rosen & Barkin's 5-Minute Emergency Medicine Consult (189 page)

DIAGNOSIS

Both will present as a unilateral, red, painful eye.

May present as an acute or indolent swelling and erythema of upper eyelid

• Swelling and tenderness greatest in temporal aspect of upper lid under orbital rim:
  
  • S-shaped lid
    
• Mass may be palpable
  
• May be associated with:
  
  • Extensive cellulitis
    
  • Conjunctival injection and discharge
    
  • Increase or decrease in tear production
    
  • Ipsilateral conjunctival injection and chemosis
    
  • Ipsilateral preauricular adenopathy
    
  • Systemic toxicity may be present
    
• Normal visual acuity, slit-lamp, and funduscopic exams
  
• May cause pressure on the globe or globe displacement:
  
  • Visual distortion may occur.
    
• Chronic form: Slowly progressive, painless swelling
  

Presents as an acutely inflamed, circumscribed mass extending inferiorly and medially from inner canthus:

• Epiphora or excessive tearing—hallmark symptom:
  
  • Tear outflow is obstructed.
    
• Discharge from punctum:
  
  • Pressure on the inflamed mass may result in purulent material from the punctum.
    
  • This may be diagnostic.
    
• Cellulitis extending to lower lid may be present
  
• Low-grade fever may be present, but patient rarely appears toxic.
  

Complete eye exam, including visual acuity, extraocular movements, slit-lamp, and funduscopic exam:

• Flip lids
  
• Examine nasal passages
  

Careful inspection for evidence of extension to orbital cellulitis or meningitis is essential.

• Tests of expressed material (used to help direct specific antibiotic treatment):
  
  • Gram stain
    
  • Culture and sensitivity
    
  • Chocolate agar plating if GC suspected
    
• CBC and blood cultures
  

CT of orbit/sinus to evaluate deep-tissue extension or possible underlying disorder in dacryoadenitis particularly with recurrent cases or in children at risk for orbital cellulitis extending from dacryocystitis.

• Dacryoadenitis:
  
  • Autoimmune diseases
    
  • Lacrimal gland tumor
    
  • Hordeolum
    
  • Periorbital cellulitis
    
  • Severe blepharitis
    
  • Orbital cellulitis
    
  • Insect bite
    
  • Traumatic injury
    
  • Orbital or lacrimal gland tumor
    
• Dacryocystitis:
  
  • Insect bite
    
  • Traumatic injury
    
  • Acute ethmoid sinusitis
    
  • Periorbital cellulitis
    
  • Acute conjunctivitis
    

TREATMENT

• Early diagnosis and initiation of treatment will reduce risk of extension of infection to adjacent structures and systemic infection.
  
• Topical antibiotics may be considered to treat or avoid conjunctivitis.
  

• Cool compresses to decrease inflammation and nonsteroidal pain medication
  
• Viral etiology:
  
  • Typically self-limited inflammation
    
• Bacterial etiology:
  
  • Antibiotics
    
  • Oral for mild infection:
    
    • Cephalexin
      
    • Amoxicillin/clavulanate
      
  • IV for severe infection:
    
    • Cefazolin
      
    • Ticarcillin/clavulanate
      
• Tetanus toxoid if necessary
  
• Incision and drainage rarely necessary except in very severe cases:
  
  • Perform with consultation to facial surgery service or ophthalmology
    

• Cool compresses
  
• Analgesics
  
• If cause unclear, treat with antibiotics as with adults
  

• Drainage of infected sac is essential:
  
  • Warm compresses and gentle massage to relieve obstruction
    
  • May facilitate outflow from obstructed tract with nasal introduction of vasoconstricting agent
    
  • Incision and drainage only in severe cases:
    
    • Typically done by ophthalmology
      
    • Avoid in ED when possible
      
    • May result in fistula formation
      
  • Duct instrumentation to facilitate drainage is not indicated in acute setting:
    
    • Reserve instrumentation for nonacute setting, if necessary at all
      
    • Manipulation while duct is inflamed may cause injury to duct and permanent obstruction from scarring and stenosis.
      
  • Topical ophthalmic antibiotic drops to prevent secondary conjunctivitis
    
• Systemic antibiotics to resolve infection and prevent spread to adjacent structures:
  
  • Oral for mild infection
    
  • Intravenous when febrile or severe infection
    
• Analgesics
  

• Newborns respond well to massage and topical antibiotics in ∼95% of cases.
  
• If no resolution in 1st yr of life, may require probing of duct by ophthalmologist
  
• Children <4 yr old who develop dacryocystitis:
  
  • At increased risk for
    Haemophilus influenzae
    infection, if not immunized:
    
    • Given typical age of presentation, complete immunization is unlikely at primary presentation.
      
    • Recommended schedule 2, 4, 6, and 12–15 mo
      
  • H. influenzae
    type B carries high risk for bacteremia, septicemia, and meningitis.
    
  • Treat afebrile, well-appearing children with responsible parent with oral cefaclor or amoxicillin/clavulanate.
    
  • Administer cefuroxime IV in acutely ill patients.
    

• Amoxicillin/clavulanate (Augmentin): 500 mg (peds: 20–40 mg of amoxicillin/kg/24h) PO q8h
  
• Cefaclor: 500 mg (peds: 20–40 mg/kg/24h) immediate release PO TID
  
• Cefazolin: 500–1,000 mg (peds: 50–100 mg/kg/24h) IV q6–8h
  
• Cefuroxime: 750–1,500 (peds: 50–100 mg/kg/24h) mg IV q8h
  
• Cephalexin: 500 mg (peds: 25–100 mg/kg/24h) PO QID
  
• Erythromycin ophthalmic ointment: 2 drops QID to affected eye
  
• Tetracaine and phenylephrine topical solution single-dose nasal spray
  
• Ticarcillin/clavulanate: 3.1 g (peds: 200–300 mg of ticarcillin/kg/24h) IV q4–6h
  
• Trimethoprim-polymyxin ointment: 2 drops QID to the affected eye
  

FOLLOW-UP

• Adults:
  
  • Febrile or toxic appearance
    
  • Concomitant medical problems including diabetes or immunosuppression
    
  • Extensive cellulitis
    
  • Suspicion of adjacent spread with deep tissue involvement or meningitis or
    Neisseria meningitidis
    
• Children:
  
  • Acutely ill appearance
    
  • Concomitant medical problems
    
  • Extensive cellulitis
    
  • High risk for
    H. influenzae
    (nonvaccinated)
    
  • If reliable follow-up within 24 hr cannot be arranged
    

Dacryoadenitis and dacryocystitis should be referred promptly to ophthalmology:

• Patients with dacryocystitis require further evaluation to confirm complete drainage of sac and to assess need for further intervention to avoid recurrence.
  
• Availability of follow-up should be confirmed and ophthalmologic consultation should be completed prior to discharge.
  

• In cases of red eye with lid swelling, specifically examine the lacrimal structures for evidence of involvement.
  
• Skin incision and drainage of dacryocystitis should be avoided whenever possible to avoid fistula formation:
  
  • Intranasal vasoconstricting agents should be used primarily to facilitate drainage.
    

• Goold LA, Madge SN, Au A. Acute suppurative bacterial dacryoadenitis: A case series.
  Br J Ophthalmol.
  2013;97(6):735–738.
  
• Kiger J, Hanley M, Losek JD. Dacryocystitis: Diagnosis and initial management in pediatric emergency medicine.
  Pediatr Emerg Care.
  2009;25(10):667–669.
  
• Pinar-Sueiro S, Sota M, Lerchundi TX, et al. Dacryocystitis: Systematic approach to diagnosis and therapy.
  Curr Infect Dis Rep.
  2012;14:137–146.
  
• Wald ER. Periorbital and orbital infections.
  Infect Dis Clin North Am.
  2007;21:393–408.
  

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