DOS Times Vol. 26 No. 2

Subspeciality-Oculoplasty

Mild: eyelid position at pupillary border Figure 5: MGJW ptosis Figure 7: Re-enforcement test: Maximum
Moderate: eyelid position in between lift of upper eyelid is assessed by applying
pupillary border and pupillary reflex Figure 6: Upper eyelid lift with jaw resistance in opposite direction of jaw
Severe: eyelid bisects pupil movement to opposite side movement.
Bell’s Phenomenon: It is a defensive Phenylephrine test: This test is done inferior fornix of the testing eye, wait
mechanism where the patient’s for congenital simple mild ptosis. Instill 5 minutes, and assess any change in
eye moves upwards and outwards 2 drops of 2.5% phenylephrine in the the palpebral fissure and the marginal
on attempted eye closure. Bells reflex distance5. If the ptotic lid is
phenomenon is graded as good if less elevated, then Conjunctivo-mullers
than one-third of the cornea is visible, resection surgery can be planned. If no
fair if up to half of the cornea is visible, response is observed or if elevation is
poor if more than half of cornea is not adequate, external levator resection
visible, reverse if the eye moves up and surgery is planned.
inwards, and inverse if the eye moves
down and out or inwards.
Marcus Gunn jaw winking
phenomenon (MGJW): MGJW is a
synkinetic movement of the upper
eyelid on the movement of jaw in
congenital ptosis resulting from an
aberrant connection between the motor
division of trigeminal nerve controlling
the masticating movement of jaw and
motor division of oculomotor nerve
supplying levator palpebrae superioris.4
MGJW is graded based on the amount
of eyelid elevation as mild for ≤2mm,
moderate for 3-6mm, and severe for
≥7mm. (Figure 5,6,7)

Contracted socket work up Right/ Left side
• Facial symmetry
• Bony orbit(mm)-horizontal/vertical dimensions
• Sulcus deformity
• Palpebral aperture(mm)- horizontal/Vertical dimensions
• Entropion/ Ectropion
• Lid/Tendon laxity/ Dystopia
• Status/size of eyeball (anophthalmic/ ophthalmic)
• Implant
• Prosthesis (surface and colour)
• Conjunctival surface
• Forniceal dimensions (mm)

a. Superior
b. Inferior
c. Lateral
d. Medial
• Forniceal shortening/shelving
• Volume of the socket
• Volume of orbit
• Palpation of socket(implant site/mass)
• Signs of trauma (soft tissue/ bone)

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Subspeciality-Oculoplasty

Contracted socket: It is defined in a 4-6mm, and 2-4mm for superior, scratches, and irregularities, aided by the
simple term as any socket which is inferior, lateral, and medial fornices, use of a magnifying loupe or slit-lamp
unable to retain prosthesis6. Grading of respectively8. Measurements are taken biomicroscope. An excessively large and
the contracted socket is as follows7 by using a calibrated rod or scale and heavy prosthesis may aggravate lower
asking the subject to look at a fixed lid laxity and result in a dropped socket
Grade 0: Socket is lined with healthy object or asking him to look in the appearance. Close interaction with an
conjunctiva and has deep and well- opposite direction. The inferior fornix is ocularist is critical, as modification or
formed fornices important among all as it supports the replacement of a prosthesis can correct
prosthesis. upper lid ptosis, superior sulcus defects,
Grade I: Shallow lower fornix or Prosthesis: Careful evaluation of the eyelid malpositions, poor motility, and
shelving of the lower fornix pushing the ocular prosthesis is important, which mild socket contraction in selected
lower lid down and out and preventing includes searching for protein deposits, cases.
retention of an artificial eye
Entropion/Ectropion work up
Grade II: Loss of the upper and lower
fornices Right / Left eye Upper / Lower eyelid
Visual acuity
Grade III: Loss of the upper, lower, Lid position / Grade
medial, and lateral fornices Pinch test
Snap back test
Grade IV: Loss of all the fornices and Medial canthal laxity / position
reduction of palpebral aperture in Lateral canthal laxity / position
horizontal and vertical dimensions Upper/Lower lid position
Trichiasis / Distichiasis / Madarosis /
Grade V: Recurrence of contraction Margin keratinization
of the socket after repeated trial of Tarsal plate
reconstruction. Lid / Puncta / other findings
Meibomian gland orifices
Assessment of socket volume: Upon Lid retraction / sagging / ptosis / lagoph-
removal of the prosthesis, the socket thalmos (mm)
should be assessed for adequacy of the Ocular surface / Fornices
superior and inferior fornices, presence Symblepheron / Ankyloblepheron /
of symblepharon, integrity and state of Others
the conjunctival lining, position of the
orbital implant, and signs of infection or skin scar
inflammation. Palpation of the socket
cavity can reveal migration of and shape Other relevant findings
and size characteristics of the orbital
implant, as well as space-occupying Entropion: Entropion is an inward Involutional entropion is further
orbital masses. If the possibility of a turning of the lid margin and discussed below
significant orbital fracture or recurrent appendages such that the pilosebaceous
tumor exists, radiographic studies unit and mucocutaneous junction are Grading of entropion (Kemp and
with computerized tomography are directed posteriorly towards the cornea Collin):
indicated. The subjective method for and ocular surface. yy Minimal- apparent migration
assessing volume of the socket is by
comparing relative depth with that of Etiological classification: of meibomian glands,
other normal eye. The objective method 1. Involutional conjunctivalization of the lid margin,
of assessment is by slowly injecting drop 2. Spastic and lash-globe contact on up gaze.
by drop in the socket after opening the 3. Cicatricial yy Moderate- apparent migration
eyelids with a speculum. The amount of 4. Congenital of meibomian glands,
normal saline that can be instilled is the conjunctivalisation of the lid margin,
volume of the socket. Superior sulcus
deformity and ptosis are also indicators
of volume loss.

Fornix dimensions: In healthy
subjects, the normal range for forniceal
dimensions are 12-16mm, 8-12mm,

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Subspeciality-Oculoplasty

lash-globe contact in primary the time required for it to return back <2mm, 1=2-4mm; 2=4-6mm; 3=>6mm;
position, thickening of the tarsal to its normal position. Normally the lid 4= never returns to baseline even after
plate, and lid retraction. resumes position without the aid of a blink)
yy Severe- lid retraction causing blink. Grading is from 0 to 4(0= normal; Medial canthal laxity9: Pull the lower
incomplete closure, gross lid 1=returns in 2-3 seconds; 2= returns in lid laterally from the medial canthus.
distortion, metaplastic lashes, 4-5 seconds; 3= >5seconds but returns Measure displacement of the medial
presence of keratin plaques. with a blink; 4 = Never returns) punctum. It is graded from 0-4 (0=
Assessment of capsulopalpabral <1mm; 1=≈2mm; 2=≈3mm; 3=>3mm;
fascia laxity: ❑Increased depth of Lateral canthal laxity9: Pull the lower 4= never returns to baseline even after
inferior fornix ❑Diminished lower lid lid medially from the lateral canthus. blink)
excursion between extreme up-gaze and Measure displacement of the lateral
down-gaze(normal- 3-4 mm) (presence canthal corner. It is graded from 0-4(0=
of lower lid crease on downgaze is
an indirect sign of functioning lid Eyelid tumor work up
retractors) ❑Presence of the white
edge of disinserted/dehiscent lower lid 1. Site & extent – UL/LL
Retractors separated from tarsus by a 2. Size -Maximum/ Minimum
pink band of orbicularis fibers ❑On 3. Appearance/ surface
retraction of the lower lid , v-shaped 4. Color/ Pigmentation
abnormality or notching of cul-de-sac 5. Telangiectasia
at the site of dehiscence maybe seen 6. Overlying skin
❑Increased fat pad height in the fornix. 7. Loss of lid/margin tissue
Pull the lower lid margin to the level 8. Palpebral conjunctiva
of the inferior orbital rim and compare 9. Mechanical ptosis
the meniscus of Protruding fat in each 10. Ocular movements
fornix. 11. Proptosis / Globe dystopia

Ectropion: Ectropion is outward turning  Palpation
in of the eyelid margin. Extent including forniceal involvement
Surface
Etiological classification: Consistency
1. Involutional Margins
2. Spastic Fixity to underlying structures (tarsus/ bone)
3. Cicatricial  Regional spread
4. Congenital  Systemic evaluation
5. Mechanical
TNM Staging (8th edition)
Grading of ectropion:
yy Mild- only punctum is everted Basal cell carcinoma is the most glands), eyelashes (Zeis glands), and the
yy Moderate- lid margin is everted and common malignant eyelid tumor caruncle. SGC may have varied clinical
reported in the West and in some presentations, according to their site
palpebral conjunctiva is visible Asian countries like China, Singapore, of origin. Risk factors for developing
yy Severe- fornix is also visible Thailand, and Taiwan, whereas in India, sebaceous cell carcinoma include older
Pinch Test: (Horizontal lid laxity) Pull sebaceous gland carcinoma is the most age, female sex, radiation exposure,
the lower lid away from the globe and common malignant eyelid tumor10. immunosuppression, and prolonged
measure the distance between center Sebaceous cell carcinoma: Sebaceous use of thiazide diuretics. A solitary eyelid
of the lid and the ocular surface. The cell carcinoma is a malignant nodule that is firm and painless, often
normal value is 2-3mm. Readings >6 neoplasm of sebaceous glands with a yellow color, and subcutaneous
mm is considered lax. that most commonly occurs in the in location is representative of
periorbital area. The eyelid is the most sebaceous cell carcinoma. A diffuse
Snap-back Test9: (Orbicularis muscle common location of this tumor. SGC pseudoinflammatory pattern
tone) Pull the lower lid away and down preferentially develops in the eyelids characterized by unilateral eyelid
from the globe for several seconds. Note because of the abundance of sebaceous thickening has also been recognized.
glands in the tarsus (meibomian The tumor often extends into the
bulbar conjunctiva and the corneal

www.dosonline.org/dos-times DOS Times - Volume 26, Number 2, September-October 2020 103

Subspeciality-Oculoplasty

epithelium giving the appearance melanomatous skin cancer that phenylephrine in the elevation of upper
of ‘unilateral blepharitis.’ When the occurs in locations lined by superficial eyelids with ptosis. Ophthalmic Surg.
sebaceous cell carcinoma originates epithelium. Actinic keratosis, Bowen’s 1990 Mar. 21(3):173-6.
from the glands of Zeis, it can present disease, and radiation dermatoses are 6. Nesi FA, Lisman RD, Levine MR.
as an ulcerated nodule or a cutaneous all precursors to the development of Evaluation and current concepts in the
horn. It can be mistaken for squamous squamous cell carcinoma. Although management of anophthalmic socket.
cell carcinoma. An irregular yellow actinic keratosis is considered In: Smith’s ophthalmic plastic and
mass in the medial canthus can precancerous lesions, < 1% go on reconstructive surgery. 2nd ed. St. Louis:
represent a sebaceous cell carcinoma to become SCC. Squamous cell Mosby; 1998. p. 1079–124.
involving the caruncle. Lacrimal gland carcinomas, like BCCs, occur most 7. Krishna G. Contracted sockets – I
involvement often mimics a unilateral frequently on the lower eyelid. SCCs aetiology and types. Indian J Ophthalmol
blepharoconjunctivitis. It is imperative often appear as painless nodular or 1980;28:117-20
to rule out sebaceous cell carcinoma plaque-like lesions with irregular rolled 8. Kawakita, T., Kawashima, M., Murat, D.
in cases of unilateral blepharitis or edges, chronic scaling with roughened et al. Measurement of fornix depth and
conjunctivitis or in cases unresponsive patches, fissuring of the skin, pearly area: a novel method of determining the
to appropriate treatment. borders, telangiectasia, and central severity of fornix shortening. Eye 23,
ulceration. 1115–1119 (2009)
Basal cell carcinoma: Basal cell 9. Sharma G, Sawaraj S. Complicated
carcinomas originate as a neoplastic Malignant melanoma: Malignant lower lid ectropions presenting to
transformation of the basal cells of the melanoma of the eyelid skin arises tertiary care hospital in Sub-Himalayan
epidermis. BCC occurs most frequently from the malignant proliferation of Region of Himachal Pradesh and their
on the lower eyelid, followed in order melanocytes. It can arise de novo or management. Sudanese J Ophthalmol
of frequency by the medial canthus, from a pre-existing nevus. Malignant 2018;10:39-43
upper eyelid, and lateral canthus. melanoma commonly presents on the 10. Kaliki, S., Bothra, N., Bejjanki, K.M.,
Clinically basal cell carcinomas are chronically sun-exposed skin of middle- Nayak, A., Ramappa, G., Mohamed,
divided into six subtypes: nodular, aged and elderly individuals. It usually A., Dave, T.V., Ali, M.J. and Naik, M.N.,
superficial, micronodular, infiltrative, appears as a > 1 cm pigmented patch, 2019. Malignant eyelid tumors in India:
morphea form or sclerosing, and often with color variegation, including a study of 536 Asian Indian patients.
fibroepithelioma of Pinkus. Nodular tan, light brown, dark brown, and black. Ocular oncology and pathology, 5(3),
basal cell carcinomas are the most It may exhibit a darker network-like pp.210-219.
common type representing greater pigmentation. It is slowly expansile.
than 60% of all tumors. A nodular BCC Corresponding Author:
typically begins as a small translucent References
nodule or papule, often evolving into 1. Henderson JW. Orbital Tumors. 3rd Ed. Dr. Sujeeth Modaboyina, MD
the characteristic lesion composed of Oculoplasty, Tumor & Pediatric
a central ulcerated crater with pearly New York: Raven Press; 1994. Ophthalmology Services,
rolled margins. The less-common 2. Kumari Sodhi P, Gupta VP, Pandey RM. Dr. R. P. Centre for Ophthalmic Sciences,
diffuse morphea form or sclerosing type All India Institute of Medical Sciences,
typically appears as a white-pink to a Exophthalmometric values in a normal New Delhi, India
yellow plaque with indistinct clinical Indian population. Orbit. 2001; 20(1):1-9.
margins and scar-like appearance. 3. Beard C. Ptosis. 2nd ed. Sant Louis: The C
Hyperpigmentation of either type V Mosby Company; 1976:89–94
of lesion may lead to confusion with 4. Gunn RM. Congenital ptosis with
malignant melanoma. peculiar associated movements of the
affected lid. Trans Ophthal Soc UK. 1883;
Squamous cell carcinoma: Squamous 3:283-7.
cell carcinoma is a common non- 5. Glatt HJ, Fett DR, Putterman AM.
Comparison of 2.5% and 10%

104 DOS Times - Volume 26, Number 2, September-October 2020 www.dosonline.org/dos-times

PG Corner

Orbital Emphysema

Deepsekhar Das MD, Arpita Kulshrestha MD, Rachna Meel MS
Oculoplasty, Tumor & Pediatric Ophthalmology Services,
Dr. R. P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India

Introduction The development of orbital Compression of the small nutrient
Orbital emphysema was first described emphysema, after an orbital fracture, is vessels supplying the optic nerve,
by Heerfordt in 1904.[1] He described thought to involve a three-step process. which are much more sensitive to
three types of orbital emphysema. In The initiating event is the formation orbital pressure than the central retinal
palpebral emphysema, subcutaneous of a sino-orbital communication as artery, accounts for the decreased
air is confined solely to the eyelids as the a result of orbital wall fracture along vision in this stage. However, these
orbital septum is intact. It may result with a laceration in the sinus mucosa. patients may not experience diplopia
from a fracture of the lacrimal bone A forceful expiratory effort then creates because of impaired vision. Stage IV
and secondary rupture of the lacrimal a pressure gradient, which forces air orbital emphysema is characterized
sac, which is situated anterior to the into the orbit. Orbital tissue, such as fat, by a significantly elevated lOP (60 to
orbital septum. This results in entry of then falls back on this communication, 70 mmHg) and central retinal artery
air from the nose into the nasolacrimal blocking the exit of air. This creates a occlusion which can lead to irreversible
system and into the eyelids. It may also ball valve effect, allowing air to enter damage to the retina if it persists for
occur as a result of facial subcutaneous but not leave the orbit.[4] The increasing more than 90 to 100 minutes.[7]
emphysema spreading into the eyelids. volumes of entrapped air can then cause
In true orbital emphysema, there is an an acute compartment syndrome with Investigations
abnormal collection of air posterior to an vascular compromise due to central If orbital emphysema is suspected, CT
intact orbital septum. Most commonly, retinal artery occlusion. can be done to identify the anatomical
this occurs as a result of fracture of location of the air and also to detect
one or more of the bony orbital walls Clinical Features any concomitant orbital wall fractures.
and laceration of the adjacent sinus Clinical findings of orbital emphysema [8] Images in the axial plane permit
mucosa which allows communication include proptosis, diplopia, raised sensitive examination of medial and
of the sinus with the orbit. Orbito- intraocular pressure and vision loss. lateral orbital walls, while coronal
Palpebral emphysema occurs when the [5] With associated orbital fracture, images are useful in evaluating
air accumulating within orbit causes patients may also have orbital pain, fractures of the orbital floor and roof.
intraorbital pressure to increase leading restriction of extraocular movements MRI has limited role in orbital trauma
to rupture of the orbital septum. This and hypoaesthesia. and can be used to look for involvement
allows air to traverse freely from the of optic nerve, recti muscles and any
orbit into the eyelids. Stages vascular damage.
Hunts et al. described four major
Pathophysiology stages of orbital emphysema.[6] Stage Management
Trauma is the most frequent cause of I orbital emphysema is characterized Orbital emphysema is a benign self-
orbital emphysema.[2] The incidence by small amounts of intraorbital air limiting condition and in most patients,
of post-traumatic orbital emphysema that is not apparent clinically and is resolves spontaneously in two to
was reported to be 61% in one study. diagnosed radiographically. With an three weeks without compromising
[3] It is frequently associated with increase in air volume in orbit, stage II the ocular functions. There is no
isolated medial wall and combined orbital emphysema becomes clinically universally accepted algorithm for the
medial wall/orbital floor fractures. evident in the form of globe dystopia management of orbital emphysema.
[3] Other mechanisms including or proptosis. Patients may experience Most cases require only careful
infection, postoperative complications, diplopia at this stage. In stage III, observation.[2] If orbital emphysema
pulmonary barotrauma, sneezing orbital pressure increases further and is noted, the patient should be told to
and oesophageal rupture have been is transmitted directly to orbital tissues avoid nose blowing, sneezing, coughing
reported.[2] and the globe causing increased lOP. or any valsalva maneuver. Prophylactic

www.dosonline.org/dos-times DOS Times - Volume 26, Number 2, September-October 2020 105

PG Corner

Figure 1a. Image showing right eye upper emphysema to prevent possible 4. Linberg JV. Orbital emphysema
and lower eyelid swelling irreversible ischemic and compressive complicated by acute central retinal
damage to the optic nerve. A 23-gauge artery occlusion: case report and
Figure 2. Non contrast computed blunt-tipped Atkinson needle is coupled treatment. Ann Ophthalmol. 1982
tomography of head and orbit showing with a syringe and air is aspirated after Aug;14(8):747-9. PMID: 7125471.
fracture of frontal bone with air trapped in having determined the anatomical
right upper and lower eyelid. location of air on CT. However, with 5. Gauguet JM, Lindquist PA, Shaffer K.
orally administered antibiotics may this technique, authors found it difficult Orbital Emphysema Following Ocular
be prescribed if the orbital wall to judge when the needle met the air Trauma and Sneezing. Radiol Case
fracture involves an infected sinus. mass intraorbitally. So the technique Rep. 2015 Nov 6;3(1):124. doi: 10.2484/
[2] If the patient is having vision loss was modified by adding normal saline rcr.v3i1.124. PMID: 27303505; PMCID:
or orbital compartment syndrome is to the syringe.[6] This modificationnot PMC4896116.
suspected, immediate decompression only allowed monitored release of air
can be achieved using a needle-coupled bubbles but also allowed a controlled 6. Hunts JH, Patrinely JR, Holds JB,
syringe emergent decompression or release of air thus avoiding injury Anderson RL. Orbital emphysema.
with lateral canthotomy/cantholysis.[6] as a result of tissue suction into the Staging and acute management.
Treatment of orbital emphysema using needle tip. Other surgical methods for Ophthalmology. 1994 May;101(5):960-6.
a needle with a syringe was suggested decompression are lateral canthotomy PMID: 8190488.
first by Linberg. Needle decompression with/ without lateral cantholysis. No
is warranted for stage III and IV orbital other specific treatments for central 7. Hayreh SS, Kolder HE, Weingeist TA.
retinal artery occlusion are needed, Central retinal artery occlusion and
because aspiration of the air mass is the retinal tolerance time. Ophthalmology.
definitive treatment. 1980 Jan;87(1):75-8. doi: 10.1016/s0161-
6420(80)35283-4. PMID: 6769079.
References
1. Heerfordt CF. Über das Emphysem der 8. Birrer RB, Robinson T, Papachristos P.
Orbital emphysema: how common,
Orbita. Albrecht von Graefes Arch für how significant? Ann Emerg Med. 1994
Ophthalmol 1904; 58:123-150 Dec;24(6):1115-8. doi: 10.1016/s0196-
2. Zimmer-Galler IE, Bartley GB. Orbital 0644(94)70241-1. PMID: 7978593.
emphysema: case reports and review
of the literature. Mayo Clin Proc. 1994 Corresponding Author:
Feb;69(2):115-21. doi: 10.1016/s0025-
6196(12)61036-2. PMID: 8309261. Dr. Deepsekhar Das MD,
3. van Issum C, Courvoisier DS, Scolozzi Oculoplasty, Tumor & Pediatric
P. Posttraumatic orbital emphysema: Ophthalmology Services,
incidence, topographic classification Dr. R. P. Centre for Ophthalmic Sciences,
and possible pathophysiologic All India Institute of Medical Sciences,
mechanisms. A retrospective study of New Delhi, India
137 patients. Oral Surg Oral Med Oral
Pathol Oral Radiol. 2013 Jun;115(6):737-
42. doi: 10.1016/j.oooo.2012.10.021.
Epub 2013 Jan 16. PMID: 23332507

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Subspeciality-Oculoplasty

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DOS Times Quiz

DOS Times Quiz

A 23 year old female patient with complaints of outward protrusion of right eye since childhood. H/o waxing and
waning of proptosis with episodes of upper respiratory infection. There is a history of decrease in size with use of
steroids. H/o acute increase in size since past 20 days.
What is the a) Diagnosis based on history and imaging
b) Recent treatment modalities

Corresponding Author:

Dr Asha Samdani,
Consultant,
Centre for Sight, Hyderabad

ANSWER

Answer _______________________________________________________________________________________________________________________________________
Name: ________________________________________________________________________________________________ Degree: _______________________________
Designation:_________________________________________________________________________ Address:_______________________________________________
_______________________________________________________________________ State _______________________________ Pin _______________________________
Mobile No: ________________________________________________________________________________________ DOS Membership no: ___________________
Email ID: _______________________________________________________________________________________Signature: ___________________________________
Email your answer to: [email protected]

108 DOS Times - Volume 26, Number 2, September-October 2020 www.dosonline.org/dos-times

Tearsheet

Antibiotics in Orbital cellulitis

Neha Yadav, MD, Rachna Meel, MS
Oculoplasty, Tumor & Pediatric Ophthalmology Services
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India

Definition: Orbital cellulitis is the inflammation of muscle and fat behind the orbital septum.
Common Pathogens: The causative organisms of orbital cellulitis are commonly bacterial but can also be polymicrobial.
Most common bacterial organisms are Staphylococcus aureus and Streptococci species and most common fungal
organisms are Mucor and Rhizopus species.

Medical Management: Vancomycin: for MRSA coverage In cases of allergy to penicillin or
cephalosporins:
• Uncomplicated orbital cellulitis • Children: 40 -60 mg/kg per day iv
can be treated with antibiotics divided into 3 or 4 doses maximum Ciprofloxacin:
alone. daily dose 4g • Children: 20-30 mg/kg/day

• Treatment regimens are usually • Adults: 15-20 mg/kg/day IV every 8 divided every 12 hours. Max. dose
empirical -12 hours max. 2g for each dose 1.5g oral and 800 mg IV daily
+ • Adults: 400 mg IV BD or 500-750
• Duration ranges from 2 to 3 mg orally BD
weeks extending to about 4 Any one of these
weeks in severe sinusitis or bony Levofloxacin:
destruction. Ceftriaxone: • Infants 6 months or older and
• Children: 50mg/kg per dose IV once
• A routine antibiotic sensitivity children < 5 years: 10 mg/kg/dose
test should be done before or twice per day( higher dose if every 12 hourly
starting treatment. intracranial extension is suspected) • Children>5 years: 10 mg/kg/dose
• Maximum daily dose 4g/day every 24 hours, maximum dose
• Adults: 2g IV per day( every 12 500 mg
hourly if intracranial extension is • Adults: 500-750 mg IV or orally
suspected)
Cefotaxime: In cases of allergy to vancomycin:
• Children: 150 to 200 mg/kg per day Linezolid (CBC monitoring)
in 3 doses • Children < 10 years: 6mg/kg/dose IV
• Adults: 2g IV every 4 hours
q8h
Piperacillin- Tazobactam 4.5g IV q8h • Children> 10 years:
10 mg/kg/dose IV q8h
Metronidazole cover in anaerobic infections: • Adults: 600 mg IV BD
• Children: 30 mg/kg per day IV
• Adults 500 mg IV q8h Daptomycin :6 mg/kg IV q24h

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Tearsheet

In suspected fungal infections: Oral Therapy:
For uncomplicated orbital cellulitis with good response to
First line of treatment: IV antibiotics, then switch to oral therapy.

• Amphotericin B deoxycholate 1 mg/kg IV q24h Amoxicillin
• Liposomal amphotericin 3-5 mg/kg q24h • Adults: 875 mg orally every 12 hours
KFT monitoring is required with amphotericin B • Children: 45 mg/kg per day in divided doses every

In cases of aspergillus infection 12 hours or 80 to 100 mg/kg per day in divided doses
every8 hours; Maximum dose 500 mg per dose
• Voriconazole 6 mg/kg IV q12h for 2 doses, then 4 mg/kg IV Amoxicillin-clavulanic
q12h • Adults: 875 mg every 12 hours
• Children: 40 to 45 mg/kg per day in divided doses
• Voriconazole 200-300 mg PO q12h every 8 to 12 hours or 90 mg/kg per day divided every
• Posaconazole:300 mg IV BID on Day 1, then 300 mg IV 12hours (600 mg/5 mL suspension)
Cefpodoxime
qDay (2nd line treatment) • Adults: 400 mg every 12 hours
LFT monitoring is required with voriconazole and CBC • Children: 10 mg/kg per day divided every 12 hours,
monitoring with posaconazole not to exceed 200 mg per dose
Cefdinir
• Adults: 300 mg twice daily
• Children: 7 mg/kg twice daily, not to exceed 600 mg
per day

Corresponding Author:

Dr. Neha Yadav
MBBS,MD, Senior Resident,
Dr. R.P Centre for Ophthalmic Sciences,
AIIMS

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Tearsheet

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