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Year : 2020  |  Volume : 12  |  Issue : 2  |  Page : 54-56

An unusual case of periocular necrotizing fasciitis: A rare but fatal complication

Department of Ophthalmology, Dr Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India

Date of Submission10-Jul-2020
Date of Decision21-Jul-2020
Date of Acceptance03-Aug-2020
Date of Web Publication09-Mar-2021

Correspondence Address:
Dr. Aakanksha Sharma
H. No. 4, Block A, Old Type 4, Dr Rajendra Prasad Government Medical College, Kangra at Tanda, Himachal Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjopthal.sjopthal_14_20

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Necrotizing fasciitis is the infection of the superficial fascia. Periocular necrotizing fasciitis is rare because of rich vascular supply of face as compared to the other parts of the body. In most of the cases, Group A beta-hemolytic streptococci are reported. Even a trivial injury to the eyelid can lead to necrotizing fasciitis. In this case report, a patient presented with fulminant periocular necrotizing fasciitis which was managed with intravenous antibiotics and surgical debridement. Reconstructive plastic surgery was required for the remaining tissue defect and cicatricial ectropion of the lower eyelid.

Keywords: Cicatricial ectropion, full-thickness graft, fulminant periocular fasciitis, Streptococci, trivial injury

How to cite this article:
Sharma A, Tuli E, Sharma G, Mohammed N. An unusual case of periocular necrotizing fasciitis: A rare but fatal complication. Sudanese J Ophthalmol 2020;12:54-6

How to cite this URL:
Sharma A, Tuli E, Sharma G, Mohammed N. An unusual case of periocular necrotizing fasciitis: A rare but fatal complication. Sudanese J Ophthalmol [serial online] 2020 [cited 2023 Feb 9];12:54-6. Available from: https://www.sjopthal.net/text.asp?2020/12/2/54/311039

  Introduction Top

Necrotizing fasciitis is the infection of the superficial fascia which leads to secondary necrosis of the overlying skin. Necrotizing fasciitis is a rapidly progressive condition which can result in loss of the limb or life. The involvement of the face and periocular skin is very rare because of its rich vascularity.[1],[2]

Periocular necrotizing fasciitis is a rare condition which spreads rapidly along the subcutaneous soft-tissue planes. It leads to necrosis of the fascia and subcutaneous tissue, but the underlying muscles are spared.[3],[4] Initially, it may present like cellulitis that rapidly progresses to necrosis of the fascia, subcutaneous tissue, and skin and systemic toxicity and can even lead to death if treatment is not promptly started. It is more common in adults. Group A beta-hemolytic streptococcus are the commonly implicated organism, but other organisms are also known to cause it.[5] The goal of the treatment is to start broad-spectrum antibiotics and debride all necrotic tissues until viable tissue is visible.[6]

  Case Report Top

A 40-year-old male patient presented to the eye outpatient department with a history of fall two days back with a swelling around the right eye. He had a history of hot water fomentation with a water bottle one day back. Thereafter, the swelling increased drastically with blister formation and pus discharge. There was no history of loss of consciousness or any other injury. The patient did not had any history of direct injury to the eye. There was no relevant medical illness except chronic alcohol intake. There were necrotic patches with slough over both upper and lower eyelids with surrounding erythematous skin and marked swelling [Figure 1]. Visual acuity of the patient was 6/6 for both eyes, extraocular movements were unrestricted, pupillary reactions were normal, and proptosis was not present. Anterior and posterior segment examination was normal. The diagnosis of periocular necrotizing fasciitis was made clinically. Immediately, wound debridement was done with drainage of pus and culture and sensitivity was sent. All biochemical and hematological parameters were within normal limits. The patient did not complain of pain despite extensive debridement, and he was afebrile. Daily dressing and debridement of the necrosed tissue was done [Figure 2]. Injection ceftriaxone 1 g intravenous twice a day was started empirically to cover the most common causative agents. Noncontrast computed tomography (CT) showed right preseptal cellulitis extending to the right cheek. Pus culture sensitivity showed the growth of beta-hemolytic Streptococcus sensitive to penicillin, erythromycin, clindamycin, bacitracin, and vancomycin. The patient markedly improved with the ceftriaxone, so we continued with the same treatment.
Figure 1: On the day of presentation

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Figure 2: Marked improvement with signs of healing after 1 week

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Subsequent debridement and dressings led to markedly improved wound over 1 week. The wound over the upper eyelid healed completely, whereas in the lower eyelid, there was small tissue defect with cicatricial ectropion [Figure 3]. Plastic surgery consultation was sought in view of the tissue defect below the lower eyelid. Full-thickness grafting was done below the lower lid to correct ectropion and residual tissue defect [Figure 4]. Following reconstructive surgery, the patient achieved good functional and cosmetic outcome.
Figure 3: Cicatricial ectropion with tissue defect

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Figure 4: After full-thickness graft

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  Discussion Top

Periocular necrotizing fasciitis is rare but severe and potentially vision or life-threatening. It can be easily differentiated from orbital cellulitis as there was normal vision, ocular motility, and pupillary reaction. Depending on the progression of disease, three subtypes of necrotizing fasciitis have been described, i.e., subacute, acute, and fulminant. The fulminant type which was seen in our case is characterized by a very rapid onset and progression. In severe cases, it can result in circulatory shock and multiorgan failure. The acute type progresses over a few days and large areas of skin are involved. The subacute type progresses insidiously over few weeks with the involvement of localized area. Beta-hemolytic Streptococci causes fulminant, while acute and subacute types are usually polymicrobial.[7]

Depending on microbiological culture, necrotizing fasciitis can be classified into two types: Type 1 which is caused by both aerobic and anaerobic organisms and thus it is polymicrobial. Type 2 necrotizing fasciitis is caused by organisms such as Streptococci or Staphylococci or a combination of the two. Type 1 is commonly seen in immunocompromised patients, whereas patients with Type 2 often have no such immunodeficiency.

Streptococcal cocci are the most common organisms causing necrotizing fasciitis. Streptococcal M protein is the main cause of inflammation and leads to severe manifestation of necrotizing fasciitis.[6] Necrotizing fasciitis develops rapidly and commonly involves immunocompromised patients (diabetes mellitus, alcoholics, postmeasles, and malnourished children[8]), but immunocompetent patients are also involved sometimes. Trivial eyelid injury, insect bites, and eyelid surgeries may be the inciting factors in the development of necrotizing fasciitis or it may develop spontaneously. Secondary gangrene can develop due to small-vessel thrombosis of the superficial fascia of the eyelid. The subacute type progresses insidiously over few weeks with the involvement of localized area. Firm adhesions at the nasojugal fold medially and to the malar fold laterally prevent the spread of infection. If this barrier is broken, the infection spreads to the neck. The least resistance for the spread is over the nasal bridge to the contralateral eyelids. The rich blood supply of the eyelid acts as a barrier between the skin and the underlying periorbital tissue. It prevents the spread of infection to the orbit.[9]

Necrotizing fasciitis of the eyelid is different from necrotizing fasciitis in the other parts of the body. The eyelid skin is thin which lacks subcutaneous fat, leading to early recognition of the disease. It can present as erythematous skin, pain, fever, blisters over the skin with necrosed and sloughed area. Diagnosis is mainly clinical supplemented with culture reports. CT scan shows the extent of orbital and sinus involvement. Patients may experience rapid deterioration, culminating into hypotension, renal failure, and adult respiratory distress syndrome. The mortality rate is reported between 10%- 14.2% on an average.[1],[2],[3]

Treatment focuses on early surgical debridement and broad-spectrum antibiotics.[10] If left untreated, mortality is very high. Early treatment decreases both mortality and morbidity.

The incidence of periocular necrotizing fasciitis is much less than that in other parts of the body. This can result in disfigurement, lid abnormalities, exposure keratitis, loss of sight or eye, and even death. Early and extensive debridement with systemic antibiotics will lead to recovery as well as decrease the complications.

It is not a very common entity nowadays because of the widespread availability of broad-spectrum antibiotics. Multidisciplinary approach in initial stages is required in most of the cases to have better recovery and good cosmetic results.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Casey K, Cudjoe P, Green JM 3rd, Valerio IL. A recent case of periorbital necrotizing fasciitis--presentation to definitive reconstruction within an in-theater combat hospital setting. J Oral Maxillofac Surg 2014;72:1320-4.  Back to cited text no. 1
Rose GE, Howard DJ, Watts MR. Periorbital necrotising fasciitis. Eye (Lond) 1991;5:736-40.  Back to cited text no. 2
Lazzeri D, Lazzeri S, Figus M, Tascini C, Bocci G, Colizzi L, et al. Periorbital necrotising fasciitis. Br J Ophthalmol 2010;94:1577-85.  Back to cited text no. 3
Luksich JA, Holds JB, Hartstein ME. Conservative management of necrotizing fasciitis of the eyelids. Ophthalmology 2002;109:2118-22.  Back to cited text no. 4
Legbo JN, Shehu BB. Necrotizing fasciitis: A comparative analysis of 56 cases. J Natl Med Assoc 2005;97:1692-7.  Back to cited text no. 5
Påhlman LI, Mörgelin M, Eckert J, Johansson L, Russell W, Riesbeck K, et al. Streptococcal M protein: A multipotent and powerful inducer of inflammation. J Immunol 2006;177:1221-8.  Back to cited text no. 6
Tambe K, Tripathi A, J Burns J, Sampath R, et al. Multidisciplinary management of periocular necrotizing fasciitis: A series of 11 patients. Eye 2012:463-7.  Back to cited text no. 7
Aliyu I. Gangrenous peri-orbital cellulitis in Nigerian children with postmeasles malnutrition. Sudanese J Ophthalmol 2015;7:22-4.  Back to cited text no. 8
  [Full text]  
Amrith S, Hosdurga Pai V, Ling WW. Periorbital necrotizing fasciitis -- A review. Acta Ophthalmol 2013;91:596-603.  Back to cited text no. 9
Proia AD. Periocular necrotizing fasciitis in an infant. Surv Ophthalmol 2018;63:251-6.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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