Eye Pain and Discharge

Presentation

A 40-year-old female, with past medical history of Type I Diabetes, ESRD on Dialysis, presents with eye pain. She states that for the past week she began having “fever and chills,” and then beginning yesterday she began to have right eye pain. Today, she notes pus coming from her right eye, prompting her to come to the emergency department. She reports taking tylenol without improvement in pain. Her temperature has not been above 100.4 degrees F. She states she has never had these symptoms before. She also endorses pain with eye movement, and blurred vision in the right eye. She denies trauma to the eye or recent head injury. She did not go to dialysis today.

Initial Vitals

T 36.8 C HR 83 BP 177/119 RR 16 O2 sat 98% on RA.

• Physical Exam

  GENERAL: Alert. Well developed and well nourished. No respiratory distress

  HEAD: Head is normocephalic.

  EYES: EOMI. Pain on extraocular motion, eyes are PERRLA. Left eye crustiness, with yellow drainage from the right eye. Conjunctivitis, with limbic sparing. Intraocular pressure right eye 26, left eye 27.

  ENT: Moist mucous membranes.

  NECK: Supple. No masses. Full range of motion

  CHEST: No tachypnea. Clear to auscultation bilaterally. No wheezing, rales, or rhonchi

  CV: Regular rate and rhythm. No murmurs, rubs, or gallops

  ABDOMEN: Soft, non-distended, non-tender. No guarding. No rebound. No masses.

  BACK: No CVA tenderness. No ecchymoses.

  EXTREMITIES: Normal to inspection and palpation. No deformity

  SKIN: Warm and dry. No diaphoresis. No obvious rashes.

  NEUROLOGIC: Alert and appropriate. Face is symmetric. Speech is normal. Moves all extremities equally. Motor and sensory distally intact.

• Labs

  WBC 8.9 x10e3/mcL

  RBC 3.8 x10e6/mcL LOW

  Hgb 11.9 gm/dL LOW

  Hct 35.8 % LOW

  MCV 95.0 Femtoliters

  MCH 31.6 pg

  MCHC 33.2 gm/dL

  RDW-CV 12.5 %

  Plt 233 x10e3/mcL

  MPV 10.4 Femtoliters

  Neut % Auto 58.8 % NA

  Lymph % Auto 21.9 % NA

  Mono % Auto 10.0 % NA

  Eos % Auto 8.1 % NA

  Baso % Auto 0.9 % NA

  Immature Grans % 0.3 % NA

  Neut # Auto 5.2 x10e3/mcL

  Lymph # Auto 1.9 x10e3/mcL

  Mono # Auto 0.9 x10e3/mcL

  Eos # Auto 0.7 x10e3/mcL HI

  Baso # Auto 0.1 x10e3/mcL

  Immature Grans # Auto 0.0 x10e3/mcL

  Glucose Level 84 mg/dL

  Sodium 139 mmol/L

  Potassium 4.0 mmol/L

  Chloride 102 mmol/L

  CO2 22 mmol/L

  Anion Gap 15 mmol/L

  BUN 72 mg/dL HI

  Creatinine 9.3 mg/dL HI

  BUN/Creat Ratio 8 Ratio NA

  Calcium 9.0 mg/dL

  Albumin. Level 3.1 gm/dL LOW

  TP 7.5 gm/dL

  A/G Ratio 0.7 LOW

  T Bili 0.3 mg/dL

  Alk Phos 88 Intl_units/L

  AST 17 Intl_units/L

  ALT 13 Intl_units/L

  Mg Lvl 2.8 mg/dL HI

  eGFR Cr 4.9 mL/min/1.73m2 NA

  eGFR Pediatric Not Reported

  Calc Osmo 298 mOsmol/kg HI

  Lipase Lvl 31 Intl_units/L

  Lactic Acid Lvl 0.9 mmol/L

  Troponin TNIH 20.4 ng/L

Imaging

CT Orbits/Sella

Radiologist Finding/Interpretation:

FINDINGS: Moderate pansinusitis. Mild soft tissue swelling around the right globe. The soft tissue swelling is all preseptal no post septal edema seen. No abscess seen.

IMPRESSION:

Moderate pansinusitis. Mild soft tissue swelling preseptal right lobe

ED Course Outcome/Discussion

There was a high suspicion for preseptal/preorbital or orbital cellulitis upon presentation. While the patinet’s labs did not show leukocytosis or lactic acid elevation, her physical exam findings of pain with eye movement and her risk factors of diabetes and ESRD were supicious for infection. A CT scan did not show findings of orbital cellulitis, but did show mild soft tissue swelling in the preseptal region of the right orbit. While the patinet’s intraocular pressure was elevated, it was bilaterally elevated. This was likely a chronic finding and was not likley due to an acute process such as narrow angle glaucoma or expanding hematoma/abscess.

The patient was given ceftriaxone and vancomycin for antibiotic coverage. Transfer for ophthalmology care was initiated, and patient was transferred to a tertiary care center for further management.

Takeaway Points

• Early antibiotic coverage should be initiated for patients with a presentation concerning for preorbital/preseptal or orbital cellulitis

• Obtain intraocular pressures prior to transfer in case the patient requires a lateral canthotomy, which can occur in nontraumatic cases due to expanding hematoma or abscess pocket

• Pain with extraocular movement is the most specific exam finding for distinguishing preorbital/preseptal cellulitis or orbital cellulitis.

• Special thanks to Dr. Brandyn Bobb for this case! Have a cool case that you would like to share? Please email thomas.rauser@uhsinc.com or scan the QR codes in the conference room or TVH ED.