Orbital pseudotumor

Background

• Also known as idiopathic orbital inflammation
• Swelling of any area of the orbit
• Diagnosis of exclusion
• Chronic condition characterized by orbital sclerosis and relapses

Clinical Features

• Proptosis
• Chemosis
• Cranial nerve palsy
• Diplopia
• Pain

Differential Diagnosis

Periorbital swelling

Proptosis

• Normal IOP
  • Orbital cellulitis
  • Orbital pseudotumor
  • Orbital tumor
• Increased IOP
  • Retrobulbar abscess
  • Retrobulbar emphysema
  • Retrobulbar hemorrhage
  • Ocular compartment syndrome
  • Orbital tumor

No proptosis

• Periorbital cellulitis/erysipelas
• Dacryocystitis (lacrimal duct)
• Dacryocele/Dacryocystocele
• Dacryostenosis
• Dacryoadenitis (lacrimal gland)
• Allergic reaction
• Nephrotic Syndrome (pediatrics)

Lid Complications

• Blepharitis (crusts)
• Chalazion (meibomian gland)
• Stye (hordeolum) (eyelash folicle)

Other

• Subperiosteal abscess
• Orbital abscess
• Cavernous sinus thrombosis
• Conjunctivitis
• Contact dermatitis
• Herpes zoster
• Herpes simplex
• Sarcoidosis
• Granulomatosis with polyangiitis

Evaluation

• CT Orbit with IV contrast
  • Evaluate for tumor vs infectious etiology
  • Imaging findings may be similar to orbital cellulitis
• MRI orbit gold standard

Management

• Vancomycin 15-20mg/kg IV BID + (one of the following)
  • Ampicillin/Sulbactam 3 g IV q6hr OR
  • Ticarcillin/Clavulanate 3.1 g IV q4h OR
  • Piperacillin/Tazobactam 4.5 g IV q6h OR
  • Ceftriaxone 2 g IV q12hr OR
  • Cefotaxime 2 g IV q4h

Pediatric:

• Vancomycin 15mg/kg IV q6hrs + (one of the following)
  • Ampicillin/Sulbactam 50mg/kg IV q6hrs (max 3g/dose) OR
  • Piperacillin/Tazobactam 100mg/kg IV q8hrs (max 4.5g) OR
  • Ceftriaxone 50mg/kg IV q12hrs (max 2g/dose) OR
  • Cefotaxime 50mg/kg IV q6hrs (max 2g/dose)
• Dramatic improvement with steroids in 24-28 hours (in consultation with ophthalmology)

Consults

• Ophthalmology

Disposition

• Discharge with close ophthalmology followup

Complications

• Vision loss
• Oculomotor dysfunction