Periocular necrotizing fasciitis with visual loss pathogenesis and treatment

Abstract

Objective: To illustrate the role of clinically necessary aggressive subcutaneous debridement with limited excision of necrotic skin in treating necrotizing faciitis, while demonstrating the histopathologic basis of orbital spread and blindness complicating this disorder.

Design: Observational retrospective case series.

Participants: Seven consecutive patients cared for by the Eye Plastic and Orbital Surgery Services at the University of Michigan and University of Iowa.

Methods: Retrospective review of ocular findings, systemic features, management, outcome, and histopathology of debrided tissue from 7 patients with periocular necrotizing fasciitis.

Main outcome measures: Patient survival and morbidity.

Results: Bilateral involvement was present in 6 of the 7 patients. Five patients suffered ophthalmic or central retinal artery occlusion with loss of vision. All patients underwent extensive debridement of subcutaneous tissue with sparing of overlying nonnecrotic skin and intensive systemic antibiotic therapy. Four patients required unilateral exenteration. After a mean follow-up of 38 months, 6 patients were alive; 1 died perioperatively due to septic shock. Histopathology, not previously described, showed inflammation to spread preferentially along eyelid fibrofatty-fascial tissue planes into the orbit and along orbital fibrous septae, leading to intense perivascular inflammation, thrombosis, and ocular infarction.

Conclusions: Necrotizing fasciitis is a potentially fatal disease that often causes blindness when affecting the periocular region. To reduce morbidity and mortality in severe infections, prompt subcutaneous debridement and limited resection of necrotic skin are usually necessary.