Orbital Necrotizing Fasciitis

A patient found down by EMS with left orbital swelling for 2 days after he was unable to take his medications due to a recent illness. He was admitted to a hospital and treated for diabetic ketoacidosis, Group A Streptococcus sepsis and left orbital infection before presenting to an ophthalmic emergency room for further eye care. At presentation, right eye was within normal limits, however in the left eye his vision was no light perception with an afferent pupillary defect and diffusely restricted extraocular movements. Anterior exam was notable for extensive periorbital swelling, bruising, lesions in various stages of healing, irregular chemosis, diffuse Decemet’s folds and endopigment, and 4+ cells and flare in the anterior chamber. Posterior exam revealed patchy areas of retinal whitening and chorioretinal folds throughout the retina. CT and MRI of the orbits with contrast revealed foci of gas and necrotizing infection suggesting a diagnosis of necrotizing orbital fasciitis. Given the poor prognosis for the left orbit, the patient underwent left orbital exenteration, followed by 5 days of hyperbaric oxygen therapy and Ceftriaxone 2 grams IV every 24 hours and 6 weeks of metronidazole 500mg orally daily. 2 months post-operatively, the patient was doing well, with no discharge at the skin/lateral wall interface, and the central exenteration socket appeared granulated. Necrotizing soft-tissue infections (NSTIs) are highly lethal, and β-haemolytic Streptococcus A is the most common causative organism. Only 10% of NF involves the head and neck areas, and only very rarely does it involve the periorbital area. Early surgical debridement is the mainstay of treatment, along with adjunctive antimicrobial therapy.

Presentation Date: 12/14/2023

Issue Date: 12/22/2023