Necrotizing fasciitis is a severe, potentially vision-threatening or life-threatening bacterial infection involving the subcutaneous soft tissues, particularly the superficial and deep fasciae. A variety of organisms may cause this disorder, including aerobic and anaerobic, gram-positive and gram-negative bacteria, but the organism most commonly responsible is group A β-hemolytic streptococcus.
This infection develops rapidly and requires immediate attention because it is potentially fatal. Although most patients are immunocompromised, it may occur in immunocompetent patients as well. The initial clinical presentation is similar to that of orbital or preseptal cellulitis, with swelling, erythema, and pain, but it may be accompanied by a shocklike syndrome. Because necrotizing fasciitis tends to track along avascular tissue planes, an early sign may be anesthesia over the affected area caused by involvement of deep cutaneous nerves. In addition, reports of disproportionate pain may suggest the presence of necrotizing fasciitis, as do skin color changes that progress from rose to bluegray, with bullae formation and frank cutaneous necrosis. Usually, the course is rapid, and the patient requires treatment in an intensive care unit.
Treatment includes early surgical debridement along with IV antibiotics (Fig 4-3). If the involved pathogen is unknown, broad-spectrum coverage for gram-positive and gramnegative as well as anaerobic organisms is indicated. Clindamycin is effective in treating infections due to most causative organisms and acts against the toxins produced by group A streptococcus. To limit the inflammatory damage associated with the toxins, adjunctive corticosteroid therapy after the start of antibiotic therapy has been advocated. Some cases of necrotizing fasciitis can be cautiously followed with systemic antibiotic therapy and with little or no debridement, including cases that are limited to the eyelids, such those with clearly defined margins, and in which the patient shows no signs of toxic shock.
Patients may experience rapid deterioration, culminating in hypotension, renal failure, and adult respiratory distress syndrome. Although clinical series from all body sites report up to a 30% mortality rate, usually due to toxic shock syndrome, this occurs less commonly in patients who have infection in the periocular region.
Figure 4-3 Necrotizing fasciitis. A, A patient with marked erythema and induration with early bullae formation. B, Axial computed tomography (CT) imaging study shows the spread of infection along preseptal fascial planes. C, Photograph taken immediately postoperatively demonstrates debrided tissues and drain. D, Photograph of patient after extensive debridement and systemic antibiotic therapy.
(Courtesy of Julian D. Perry, MD, and Catherine J. Hwang, MD.)
Lazzeri D, Lazzeri S, Figus M, et al. Periorbital necrotising fasciitis. Br J Ophthalmol. 2010;94(12):1577–1585.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.