1. Ophthalmic exam. Check both eyes for swelling of eyelids, redness of conjunctiva, movement, and associated pain. Inspect for gross anatomic defects (proptosis). Note any discharge (color and consistency). Vision, pupils, and motility should be normal.
2. Complete physical exam. Should always be done to rule out signs of systemic infection. Pay particular attention to oropharynx and ears.
B. Laboratory Data. Studies in older children are usually not warranted; diagnosis typically is based on history and physical exam.
Gram stain and culture are obtained in neonates to rule out gonococcal and chlamydial disease.
1. Gram-stained smear of discharge. Can be done quite rapidly. Check for WBCs and presence of bacteria.
a. Neisseria gonorrhea. Gram-negative intracellular diplo-cocci.
b. S aureus. Gram-positive cocci in clusters.
c. Pseudomonas aeruginosa. Gram-negative bacilli.
d. Streptococci. Gram-positive spherical cocci.
e. Enterococci. Gram-positive, lancet-shape, encapsulated diplococci.
f. Hinfluenzae. Gram-negative coccoid rods.
g. Chlamydia trachomatis, HSV (or other viruses), chemical, or allergic conjunctivitis. Gram-negative.
2. Culture and sensitivity testing of discharge. Identifies specific organism, but results are not available for several days. Special transport media are required for viral specimens (eg, Thayer-Martin for gonococcal).
3. Giemsa stain. Obtain if chlamydial infection is suspected to check for cytoplasmic inclusion bodies within epithelial cells. Presence of many eosinophils may indicate an allergic cause.
C. Radiographic and Other Studies. Usually are not required. CT scan with thin orbital slices may be useful for patients in whom orbital cellulitis is suspected.
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