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G. Wang, J. Egbert, T.J. McCulley; Periorbital Necrotizing Fasciitis . Invest. Ophthalmol. Vis. Sci. 2005;46(13):5059.
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Purpose: To describe periocular necrotizing fasciitis and its management. Methods: Interventional case series. Results: Case 1: A 55 yo healthy male presented with erythema of the left upper eyelid one day following injury with a woodchip. Oculoplastic consultation was sought following three days of oral cephalexin. Examination demonstrated marked swelling of the entire upper eyelid and adjacent brow. The involved area was anesthetic and had a violaceous hue. The exam was otherwise normal. A lidcrease incision revealed subcutaneous necrotic tissue underlying the involved area; orbital septum appeared intact. MRI demonstrated enhancement along the lateral rectus and culture grew S. aureus. In addition to broad spectrum antibiotics, management included daily debridement and hyperbaric oxygen therapy. After one week, the remaining skin was closed primarily and the patient continued to do well. Case 2: A 37 yo male suspected to be HIV positive presented with a one week history of left upper eyelid swelling and proptosis. Visual acuity was 20/100 with an RAPD and limited extraocular motility. CT demonstrated a fluid collection at the left upper eyelid extending near the orbital apex. An anterior orbitotomy through a lidcrease incision was performed with aggressive debridement of diffusely necrotic tissue of the upper eyelid and superior orbit. Culture grew S. aureus. Following 48 hours of broad spectum antibiotic therapy, minimal additional necrotic tissue was excised on repeat surgical exploration. The patient continued to recover over the following 72 hours with improved vision and motility, but left the hospital against medical advice on oral antibiotics; further follow–up is not available. Case 3: A 43 yo female with rheumatoid arthritis and autoimmune hepatitis maintained on azathioprine and prednisone presented to her primary care doctor with diffuse myalgias and was treated with pulse steroids for 3 days. She then developed erysipelas of the right side of her face and purulent orbital cellulitis. Initial eye exam included blindness and anterior segment ischemia with a frozen globe. Orbital cultures grew strep pyogenes. Surgical exploration demonstrated diffuse necrosis of the eyelids, conjunctiva, and deep orbital tissues. Despite initial debridement and IV antibiotic therapy, disease progression necessitated orbital exenteration 2 weeks later. Conclusions: Necrotizing fasciitis may involve the periorbital area, and if early disease control is not achieved, orbital involvement necessitating exenteration may occur.
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