|Year : 2014 | Volume
| Issue : 3 | Page : 145-148
Determinants and outcome of peri-orbital necrotizing fasciitis: Experience from a tertiary care center
Padma B Prabhu, Raju Kuzhupally Vallon
Department of Ophthalmology, Government Medical College, Kozhikode, Kerala, 673008, India
|Date of Submission||11-Jul-2013|
|Date of Acceptance||08-Mar-2014|
|Date of Web Publication||16-Aug-2014|
Dr. Padma B Prabhu
Associate Professor, Department of Ophthalmology, Govt. Medical College, Kozhikode, Kerala, 673008
Source of Support: None, Conflict of Interest: None
We attempt to describe the determinants and outcome of severe soft tissue infections affecting the eye (peri-orbital necrotizing fasciitis or PNF), a rare entity caused by toxin-producing, virulent bacteria. Our series of six adult cases of PNF included patients with and without co-morbidities. Minor trauma and adjacent focus of infection preceded the development of PNF in four cases. No source of infection could be identified in two patients. Patients with no apparent co-morbidities recovered rapidly with aggressive antibiotic therapy and surgical debridement. However, all the patients who had associated co-morbidities showed a protracted course, two of them with complications. Surprisingly, in majority (5 out of 6), culture grew group A beta-hemolytic streptococcus. Thus, our case series points to the importance of early detection and aggressive treatment of associated co-morbid conditions to avoid complications of this life-threatening, yet treatable disease.
Keywords: Debridement, fasciotomy, necrosis, necrotizing fasciitis, palpebro-orbital
|How to cite this article:|
Prabhu PB, Vallon RK. Determinants and outcome of peri-orbital necrotizing fasciitis: Experience from a tertiary care center. J Clin Ophthalmol Res 2014;2:145-8
|How to cite this URL:|
Prabhu PB, Vallon RK. Determinants and outcome of peri-orbital necrotizing fasciitis: Experience from a tertiary care center. J Clin Ophthalmol Res [serial online] 2014 [cited 2022 Dec 3];2:145-8. Available from: https://www.jcor.in/text.asp?2014/2/3/145/138858
Peri-orbital infections are exceedingly common to the ophthalmologist. But, they rarely spread extensively as to be life-threatening. Necrotizing fasciitis is a rare type of peri-orbital infection, caused by toxin-producing, virulent bacteria with a mortality rate of 14.42%. However, peri-orbital necrotizing fasciitis (PNF) is not common due to the rich vascularity of the face.  Necrotizing fasciitis, though well recognized, has been inadequately documented in ophthalmic literature.
| Materials and Methods|| |
This study is a retrospective analysis of cases diagnosed and treated as PNF at our institution, during a period of five years (2007-2012). Cases were suspected based on the following criteria. 
- Pain in and around orbit, out of proportion to the physical findings
- Sign of systemic toxicity like high-grade fever, headache, and prostrations, with otherwise non-specific history and physical examination
- Diffuse erythema
- Indistinct margins
- Necrotic skin with dusky blue blisters or bullae
- Copious foul smelling serosanguinous discharge
- Undermining of the normal skin
Patients with erysipelas, herpes zoster ophthalmicus, and orbital cellulites were excluded. Detailed ocular examination, pus cultures and wound swabs, investigations like complete blood count with erythrocyte sedimentation rate (ESR), random blood sugar (RBS), serum electrolytes, renal function tests, peripheral smear and liver function tests, neuro-imaging in relevant cases of trauma were done. The necrotic skin was sent for histopathology to confirm the diagnosis. All patients were managed medically by broad spectrum antibiotics and surgical debridement.
| Results and discussion|| |
Six patients satisfied the diagnostic criteria of necrotizing fasciitis. Case 1 and 2 had uncontrolled diabetes and diabetic nephropathy. The subject with metabolic encephalopathy (Case 3) had history of hypertension with stroke of two years duration, had sustained a fall two weeks prior, and was comatose with subarachnoid hemorrhage and facial bruises with ecchymosis both lids of either eye. The patient developed septicemia, multi-organ failure, and succumbed to death. Case 4, a 40-year-old female with infiltrative duct carcinoma breast was on neoadjuvant chemotherapy with Adriamycin. Painful swelling of right maxillary area and lower lid followed a nasal furuncle. The 47-year-old male (Case 5) had an infected traumatic lid hematoma, which ended up in necrotizing fasciitis. He had no known risk factors leading to immunosuppression. The 62-year-old female with spontaneous onset of PNF (Case 6) presented with fever, pre-septal edema, tenderness of right upper lid, and arthritis of both knee joints. She was not on any systemic medications.
Histopathology in four cases revealed obliterative vasculitis with necrosis and polymorphonuclear infiltrate. Specimen was insufficient in 1 case. Group A β-hemolytic streptococci was isolated in five cases and methicillin-resistant staphylococcus aureus (MRSA) in one case. Imaging was normal in the respective cases.
The initial regimen included inj. Cefazolin 1 gm intravenously twice daily IV twice daily, inj. Amikacin 250 mg twice daily, and inj. Metrogyl 500 mg thrice daily. Inj. Crystalline Penicillin was added in two cases with no improvement within 24 hours. The case with culture isolate of MRSA was given inj. Vancomycin 1 gm intravenously twice daily. Parenteral antibiotics were given for 14 days.
Under aseptic precautions, the wound debridement was done on a daily basis. All necrotic tissue was excised till bleeding was noticed which was suggestive of the limit of infiltration and damage. The debrided area was cleaned with hydrogen peroxide followed by application of Metrogyl ointment and medicated surgical dressing. The dressing was continued till healthy granulation tissue started appearing in the wound base [Figure 1], [Figure 2] and [Figure 3]. The wound was then left open for healing by secondary repair. Recovery ranged from eight days to 53 days. Plastic reconstruction with split skin graft was required in one case [Figure 4].
The cases are summarized in [Table 1].
- The two patients who had no co-morbidities (cases 5 and 6) had localized involvement (only right upper lid was involved), recovered faster (~1 week), and suffered no long-term complications. The outcome was independent of the precipitating event namely trauma (case 5) or spontaneous (case 6). However, it can be considered that PNF would have developed from an undetectable or a healed focus of infection in the patient with spontaneous onset of the disease. 
- Patients who had underlying co-morbid risks like diabetes mellitus or cancer chemotherapy (cases 1, 2, 4), in spite of presenting as promptly as the other 'no risk factor' group (around 3 days) took longer time to recover (about 4 weeks) and one of them did so with complications like scarring. This implies that the development of subcutaneous fasciitis and its course are driven predominantly by co-morbidities of the host possibly by affecting immunocompetency rather than microbial virulence as the infection was predominantly monomicrobial with same microbe in all the patients as among the 'no risk factor' group.
- Local trauma can directly inoculate diverse genera of microbial commensals and environmental microbes into the subcutaneous tissue. Moreover, majority of extraocular skin appendageal infections like furuncle or hordeolum are predominantly caused by pyogenic staphylococci. In overwhelming majority (5 out of 6 cases) in this series, subcutaneous palpebral infection leading to necrotizing fasciitis was consistently caused by group A hemolytic streptococcus. This argues against spread of localized infection as the sole driving factor for development of peri-orbital necrotizing fasciitis. ,,
- The lack of anaerobic organisms consistently observed in our cases correlates with the rich vascularity and hence oxygenation of peri-ocular soft tissue. The consistent monomicrobial pattern of infection with group A beta-hemolytic streptococcus in peri-orbital soft-tissue infections is also in stark contrast to the polymicrobial and anaerobe-rich growths observed in necrotizing fasciitis elsewhere in the body and suggests unique biological properties of peri-ocular soft-tissue. 
- The presence of multiple host-related risk factors, the comatose state which prevented early recognition and prolonged hospitalization with acquisition of antibiotic-resistant MRSA had lead to disseminated infection, multi-organ failure, and death of the patient (case 3). ,,,
- It is observed that neutropenia is more common in PNF due to pseudomonas infection, whereas leukocytosis is more common in beta-hemolytic streptococcus. We noted leukopenia in four cases, irrespective of the causative organism or associated co-morbidities. A small cohort without significant statistical power is a limitation of this series.
| Conclusion|| |
To summarize, our series of cases of this rare infectious entity, namely, PNF shows a striking diversity in patient-co-morbidity-related risk factors, which correlates well with their disease outcome. Yet, the microbial etiology remains consistent across cases in spite of the variability in recognizable sources of spread. This strongly suggests a predominant role for host-related co-morbid factors, possibly immune-associated, in the progression of an otherwise potentially-treatable infection of the peri-orbital soft tissue. Hence, our series should prove to be of potential interest to clinicians across disciplines and ophthalmologists in particular, to recognize early and treat relatively common sources of peri-ocular infection more aggressively in patients with co-morbidities.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]