Preseptal or Orbital Cellulitis Clinical Pathway, All Settings – History and Physical Exam

Preseptal or Orbital Cellulitis Clinical Pathway — All Settings

History and Physical Exam

Photographs

Document eyelid and eye appearance in the medical record with photographs, using Haiku or Canto.

Include:

  • Frontal facial view
  • View from above (to assess for proptosis)

History and Physical

History
  • Eye Symptoms
    • Eyelid swelling
    • Eye bulging
    • Pain with eye movements
    • Double vision
    • Decrease in vision
    • Red eye
    • Eye discharge
  • Precipitating events
    • Upper respiratory illness
    • Recent eye or eyelid trauma
    • Insect bite
    • Facial or dental infection
    • Prior eye, orbital, or sinus surgery
  • Additional symptoms
    • Fever
    • Allergy symptoms
    • Significant headache
    • Lethargy
    • Facial pain
    • Stiff neck
    • Vomiting
    • Mental status change
  • Prior history of
    • Similar presentations
    • Ocular or orbital disease, surgery
    • Sinusitis or sinus surgery
    • Recent antibiotic course or treatment
    • MRSA history
    • Allergies
Systemic Physical Examination
  • General appearance
  • Mental status
  • Fever
  • Vital signs
  • Neurologic exam, evaluate for evidence of meningitis
  • Signs of systemic disease or infection

Eye Examination

Visual Acuity
  • Assess each eye separately, with glasses if applicable
  • Test using the highest possible method:
    • Eye chart or card at correct distance (Snellen acuities)
    • Fixates on a target and follows
    • Perceives light
Motility Eye should move completely up, down, left, and right
Pupil
  • Both pupils are round and equal in size
  • Each pupil constricts to light
  • Check for relative afferent pupillary defect (RAPD) in involved eye
    • Shine light on one pupil, both pupils constrict
    • Quickly swing the light to the other pupil
      • Normal response: both pupils constrict
      • Abnormal response: both pupils enlarge (confirmed RAPD)
Eyelid and Orbit
  • Lid swelling, erythema, warmth, tenderness
  • Discharge on lashes
  • Proptosis (forward displacement of the eyeball, not the eyelids)
Ocular Surface
  • Red (injected) or swollen (chemotic)
  • Cornea clear (iris clearly visible underneath)
Red Reflex Clear, present and symmetric red reflexes in both eyes
Optic Nerve Head Swelling or pallor

If eyelids are too swollen or child is uncooperative, try the following techniques to open the eyes enough to visualize the ocular surface:

  • Place fingers on eyelid margins to pull lids apart
  • Use cotton tip applicators to evert lid margin and pull lids apart
  • Use eyelid speculum after administration of topical numbing drops
  • If unable to assess the ocular surface (the eye itself under the lids), consult ophthalmology service