Throughout each premed virtual shadowing session, you will actively participate by answering and asking questions about the week’s proposed case. Like an in-person shadowing experience, we strive to stimulate students intellectually and ultimately reaffirm their interest in medicine.
Introduction – Orbital Cellulitis
Here’s another great case in emergency medicine and ophthalmology. Orbital cellulitis is a condition which can develop from trauma to the eye creating a niche for infection, a bug bite or even a stye. Due to the fact that the infection is WITHIN the orbit itself (and not just the soft tissue around the eye (AKA periorbital cellulitis)), the patient must be treated quickly to prevent severe complications such as brain abscess or blindness. Follow along with the case below to learn how to recognize, diagnose, and treat a patient with orbital cellulitis.
(revisit this section as you go through the case and physical exam so you understand the terminology).
Periorbital swelling: skin around the eye is swollen
Proptosis: Protrusion of the eye from its socket
PERRL: Pupils equal round and reactive to light
Conjunctiva: Whites of your eyes and lining of inner eyelids
Visual acuity: 20/20 is normal (20/40 means a patient with normal acuity can see the object from 40 feet, while the patient with abnormal visual acuity must be 20 feet to see it)
EOM (extraocular movements) appears full with symmetric corneal light reflex: Extraocular movements (eye movements), using a light to check if the eyes are centered normally
Nystagmus: Involuntary jerking eye movements
Diplopia: Double vision (seeing two of something)
A 39-year-old male presents to the emergency department with a chief complaint of right-sided headache. He thinks that he first noticed the pain 3 days ago, but notes that he is a security guard and was punched in the right face 2 weeks ago (all the bruising around his right eye has since resolved). He describes the pain as a dull ache around his right eye. He denies any throbbing sensation, photophobia (light makes pain worse), phonophobia (sounds make pain worse). However, he does admit to diplopia (double vision) and sharp pain with eye movements when looking left, right, and down. He says the double vision stops when he covers one eye. He has not taken anything to treat his symptoms and says nothing makes his pain better.
No acute distress. He had mild-moderate right-sided periorbital swelling and erythema. No discharge or proptosis. Eyes had PERRL. Conjunctiva are clear bilaterally. Visual acuity: 20/40 without correction at 14 inches. Full visual fields. EOMs appear full with symmetric corneal light reflex and no nystagmus. Patient endorses diplopia and ocular pain with left, right and downward gaze. Ocular pressure normal with tonopen.
In order to best treat your future patients, you must think carefully about your assessment (differential diagnosis) and be able to rule out the other conditions that may develop in a similar fashion. For our patient, we want to consider the following:
Take home points