Authors: Karim Punja, Derek Mai, Alexander Ragan, Brett Byers, Alejandra Ugarte Torres, Michael Ashenhurst

Author Disclosure Block: K. Punja: Membership on advisory boards or speakers’ bureaus; Alcon Canada Inc., Allergan Inc., Clarion Medical Technologies. Description of relationship(s); Consultant/Advisor. D. Mai: None. A. Ragan: None. B. Byers: None. A. Ugarte Torres: None. M. Ashenhurst: None.

Abstract Body:

Purpose: We review the salient features of periorbital necrotizing fasciitis (NF) and showcase the medical, surgical and reconstructive outcome in a patient with fulminant Group A Streptococcusorbital and facial NF.
Study Design: Case study
Methods: Periorbital necrotizing fasciitis (NF) is a rare clinical occurrence in the spectrum of orbital infectious diseases, but one that requires a high index of clinical suspicion, timely diagnosis, and urgent treatment due to its blinding and life-threatening potential from systemic sepsis and shock. Periorbital NF can occur as a rapidly progressive and fulminant orbital cellulitis in a patient with immunosuppression, and Group A Streptococcus is the most common culprit. However, the causative source can be polymicrobial or even fungal and can also wreak havoc on immunocompetent individuals. Imaging studies may be helpful but not pathognomonic. Virtually all NF cases are treated with intensive intravenous antibiotics and urgent debridement.
We report a case of severe orbital and facial group A Streptococcus NF in a 58 year-old Caucasian male with multiple medical and socioeconomic issues including polysubstance abuse, blunt trauma, and homelessness. Computed tomography (CT) findings of possible infection were initially reported to be confined to the preseptal tissue. Within hours, the infection, which originated in the left medial orbit, progressed to affect the entire left orbit and extended toward the left ear and cheek.
Results: He was promptly treated with intravenous penicillin G and clindamycin in the intensive care unit and underwent urgent serial surgical debridements, which resulted in a large tissue defect approximately 12cm x 7cm in the left periorbital area and left face. Fortunately, the globe remained unpenetrated, and he was able to retain some vision in the setting of chronically poor visual acuity from previous traumatic optic neuropathy with pallor on dilated eye exam. The patient underwent successful left periorbital and eyelid reconstruction with composite graft consisting of free tarsoconjunctival graft, periosteal flaps, and tissue rotational flaps with axial blood supplies. At his 1-month follow up visit, the reconstructed tissue remained healthy, and the patient was convaslescing well. Vision had improved to hand motion, limited by baseline optic neuropathy superimposed by a brunescent cataract. The view of the fundus was extremely limited, and B-scan ultrasound did not indicate retinal pathology. Unfortunately, due to poor socioeconomic factors, the patient never returned for further follow-up despite numerous attempts to reach him.
Conclusions: We present the clinical and reconstructive course of a case of severe periorbital and facial necrotizing fasciitis (NF) and emphasize the need for timely diagnosis and management of this potentially life threatening disease.