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INFECTIONS AND INFLAMMATION

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Preseptal (Periorbital) and Postseptal (Orbital) Cellulitis

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Preseptal cellulitis is an infection of the periorbital tissues, whereas postseptal cellulitis involves the orbit. Both conditions primarily present in children <10 years old. They may present nearly identically with typical symptoms of excessive tearing, erythema, warmth, tenderness to palpation of the lids, and periorbital tissue. In preseptal cellulitis, there is NO eye involvement. That is, visual acuity, pupillary responses, and eye appearance are normal, and there is no pain with extraocular movements. If any of these characteristics are present, or if there is concern about postseptal involvement, obtain a CT scan with contrast of the orbit (or MRI) to rule out orbital involvement. Preseptal cellulitis in nontoxic patients may be treated as an outpatient with amoxicillin/clavulanic acid 20 mg/kg PO divided every 12 hours; 500 mg PO three times daily in adults or a first-generation cephalosporin, hot packs, and with 24 to 48 hours ophthalmology follow-up. In cases of preseptal cellulitis that are severe or involve high-risk patients (e.g., children <5 years or patients with significant comorbidities) or in any case of postseptal cellulitis, obtain an emergent ophthalmology consultation for admission for intravenous antibiotics. Empiric therapy should begin with cefuroxime 50 mg/kg IV every 8 hours or ceftriaxone 50 mg/kg every 12 hours, or ampicillin–sulbactam 50 mg/kg IV every 6 hours, with IV vancomycin added if methicillin-resistant Staphylococcus aureus (MRSA) is suspected. Use fluoroquinolones PLUS metronidazole or clindamycin in penicillin allergic adults.

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Stye (External Hordeolum) and Chalazion

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A stye is an acute infection of an oil gland at the lash line that appears as a pustule at the lid margin. A chalazion is an acute or chronic inflammation of the eyelid secondary to meibomian gland blockage in the tarsal plate. When it is acute, a chalazion may be painful, but is usually painless when chronic. A stye or acute chalazion is treated with warm, wet compresses four times daily and with erythromycin 0.5% ophthalmic ointment twice daily for 7 to 10 days. Refer persistent or recurrent lesions to an ophthalmologist for further evaluation and treatment.

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Bacterial Conjunctivitis

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Bacterial conjunctivitis presents as eyelash matting, mild to moderate mucopurulent discharge, and conjunctival inflammation. Fluorescein staining of the cornea should be performed in patients with suspected conjunctivitis to avoid missing abrasions, ulcers, and dendritic lesions. Prescribe topical antibiotics for 5 to 7 days (Table 149-1). Quinolones (ciprofloxacin or ofloxacin ophthalmic) may be used in children due to limited systemic absorption. Avoid gentamicin due to high incidence of ocular irritation. Haemophilus influenzae and Moraxella catarrhalis are considerations in children; therefore, if erythromycin ointment is being used and is ineffective, a change in antibiotics should be initiated. Contact lens wearers should receive topical antibiotic coverage for Pseudomonas, such as ciprofloxacin or tobramycin. The lens should be discarded and not replaced until the infection has completely resolved.

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Table Graphic Jump Location
Table 149-1

Selected Ophthalmic Medications Used in the Emergency Department

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