SAQ 457 – Ophthalmology – orbital cellulitis and complaint response

Ophthalmology – orbital cellulitis and complaint response.

a. Findings and diagnosis

• Ophthalmoplegia, with the eye deviated down and out and impaired gaze.
• Proptosis/exophthalmos.
• Marked eyelid swelling and erythema.
• Injected or oedematous conjunctiva/sclera.
• Most likely diagnosis: orbital cellulitis.

b. Differential diagnoses

• Cavernous sinus thrombosis.
• Retro-orbital abscess or haemorrhage.
• Orbital floor fracture with inferior rectus entrapment if trauma is present.

c. Management priorities

• Protect vision and prevent intracranial or cavernous sinus spread.
• Commence broad-spectrum IV antibiotics urgently.
• Urgent ophthalmology review for assessment of optic nerve compromise and need for decompression or drainage.
• CT orbit/brain/sinuses if it will define abscess, retro-orbital collection or intracranial extension without delaying critical treatment.

d. Complaint response

• Acknowledge her concern and allow her to explain what happened.
• Apologise for the distress and avoid a defensive response.
• Explain the current serious diagnosis and immediate treatment plan in plain language.
• Arrange senior review, documentation and an agreed follow-up process for the earlier presentation.
• Check understanding, answer questions and give a realistic timeframe for further updates.