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Alexander Port, Benjamin Levine; Distinguishing orbital and preseptal cellulitis: how useful are clinical history and physical exam?. Invest. Ophthalmol. Vis. Sci. 2016;57(12):711. doi: https://doi.org/.
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© ARVO (1962-2015); The Authors (2016-present)
Preseptal and orbital (post-septal) cellulitis often present similarly, but must be distinguished to ensure appropriate management. This study seeks to determine whether clinical history and physical examination alone provide an accurate diagnosis of orbital cellulitis as compared to imaging findings.
We reviewed all inpatient and ED ophthalmology consultations for suspected orbital cellulitis over a 5-year period (Oct 2010-Oct 2015). Records were reviewed and analyzed with respect to demographics, exam findings, imaging findings and outcomes.
There were 139 consultations for suspected orbital cellulitis with complete records available. Of these, 89 had preseptal cellulitis, 39 had orbital cellulitis, and 11 had other diagnoses. CT or MRI imaging was available for 98 of 139 subjects (70.5%). Subjects with preseptal and orbital cellulitis differed with respect to several factors (see table 1). On forward stepwise logistic regression, a diagnosis of orbital cellulitis was associated with proptosis (OR 33.4, 95% CI: 5.2, 68.6, p = 0.001) restricted extraocular movement (OR 29.5, 95% CI: 7.1, 123.1, p = 0.001) and afferent pupillary defect (OR 19.3, 95% CI: 1.4, 68.9, p = 0.028).36 patients had at least one "orbital sign" including ophthalmoplegia, chemosis, proptosis, elevated IOP, RAPD, or dyschromatopsia. Of these, 27 demonstrated radiographic evidence of orbital involvement and 9 did not. 16 subjects were found to have 2 or more orbital signs on examination, all of whom had orbital cellulitis. The presence of at least 1 orbital sign on examination had a sensitivity of 69.2% (95%CI: 52.4-83.0%) and a specificity of 89.9% (95%CI: 81.7-95.3%) for the diagnosis of orbital cellulitis. If 2 or more orbital signs were found, examination findings had 41.0% sensitivity (95%CI 25.6-57.9%) and 100% specificity (95% CI: 95.9-100%) for orbital cellulitis.
There were significant differences in clinical history and examination findings of patients with preseptal and orbital cellulitis. Clinical exam findings had moderate sensitivity and high specificity for the presence of orbital cellulitis. In cases of suspected orbital cellulitis where imaging is unavailable or deferred, the clinical exam may reliably distinguish between patients with and without post-septal involvement.
This is an abstract that was submitted for the 2016 ARVO Annual Meeting, held in Seattle, Wash., May 1-5, 2016.
Table 1: Preseptal vs orbital cellulitis. Significant differences highlighted in bold.
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