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Child with red swelling around one eye

Clinical Discipline(s)/Organ System(s)
Ophthalmology, General Practice, Infectious Diseases, Paediatrics
Progress Test Topic(s)
Eyes
Description
A 6 year old NZ European boy presents with a warm red swelling around the right eye of 24 hours duration, to the extent he is unable to open the eye himself. He is feeling unwell, off his food, and his mother is worried that he has been 'quiet' for the last few hours. She has come to you seeking antibiotics.
Applied Science for Medicine 
   - Anatomy of the eyelid, orbit, orbital septum, glands in the eyelid, lacrimal gland, extraocular muscles and contents of the orbit
   - Physiology of vision and visual pathway, ocular motility
   - Pathogenesis of periorbital infection; skin and nasopharyngeal pathogens
   - Staphylococcus aureus/streptococci/Haemophilus influenzae type b and non-typable
   - Pharmacology of betalactam antibiotics; (flucloxacillin, amoxicillin-clavulinate, flucloxacillin, cephazolin)
Clinical and Communication Skills 
   - History from a patient and parent regarding swelling around the eye, and elicit a relevant history for sight/life threatening orbital cellulitis as distinct from other causes of lid swelling
   - Examination of the eye and periorbital area (examining the eye by opening the lids is mandatory); visual acuity, ocular motility, pupil reactions, assessment of conjunctival chemosis and injection, proptosis
   - Recognise signs of orbital extension of infection from surrounding structures; classify the extent of involvement
   - Differential diagnosis of periorbital redness and swelling; consider infection, sinusitis, blepharitis, eyelid abrasion, insect bite
   - Interpret full blood count, blood cultures, conjunctival swabs, CT orbits/sinuses
   - Management of febrile child, periorbital and orbital cellulitis, orbital abscess, septicaemia
   - Appropriate referral to otorhinolaryngology (ORL), paediatrics
   - Complications of orbital infection: orbital abscess, intracranial extension of infection, loss of vision, death
   - Prognosis of periorbital infection: recovery from febrile illness, visual recovery
Personal and Professional Skills 
   - Team work with allied professions
   - Engaging appropriately with patient, family and student if managing patient in a teaching environment
Hauora Māori 
   - Appropriate engagement and consultation with whānau
Population Health 
   - Provision of emergency ophthalmic services
   - Vaccine preventable disease (near eradication of Haemophilus influenza type b disease; previously common cause of facial cellulitis)
Conditions to be considered relating to this scenario
Common
preseptal (periorbital) cellulitis, blunt trauma, atopic eczema (dermatitis), allergic reaction, adenoviral conjunctivitis/herpes simplex virus, external hordeolum/stye, internal hordeolum/chalazion, blepharitis
Less common but 'important not to miss'
subcutaneous/orbital emphysema, retrobulbar haemorrhage, rhabdomyosarcoma, orbital cellulitis
Uncommon
blepharochalasis, erysipelas, contact dermatitis, dacryocystitis, dacryoadenitis, neuorofibroma, burn, encephalocoele, dermoid cyst, capillary haemangioma
Related Scenarios
[Watery eye in an infant]