- Rapid progression over hours to days
- In the periocular area, can advance into the orbit
- Initial antibiotic coverage
- Coverage for streptococci, staphylococci, Enterobacteriaceae, and anaerobes
- Ampicillin/sulbactam (Unasyn), Piperacillin/tazobactam (Zosyn), or Gentamicin with clindamycin or metronidazole intravenously in consultation with infectious disease consultant (Morgan, Curr Inf Dis Rep 2011)
- Tailor antibiotics to culture results and sensitivities
- Antifungals if indicated by cultures
- Correct underlying immunodeficiency if present.
- Correct underlying metabolic imbalance
- Nonsteroidal anti-inflammatory agents should be avoided as they can accelerate renal failure in these patients.
- Aggressive fluid resuscitation in patients with septic shock
Considerations for debridement versus observation (Figure 2):
- Early, wide surgical debridement recommended by most authors. Excision should continue until healthy, well perfused tissue is identified (Marshall, Ophthalmology 1997; Tambe, Eye 2012; Aakalu, OPRS 2009).
- More conservative medical management with delayed surgical debridement can be considered in cases limited to the periocular area without systemic involvement. In these cases, the devitalized but sterile tissue can remain in place until secondary reconstruction is planned weeks to months later (Mutamba, Eye 2013).
- With conservative management, it is imperative to ensure tissue destruction is not advancing. This can be accomplished by marking the area of necrosis, and monitoring closely for progression.
- If confined to the eyelids, secondary reconstruction might not be necessary at all (Luksich, Ophthalmology 2002).
Figure 2. Algorithm for the management of periocular necrotizing fasciitis.
Other management options
Negative pressure wound therapy (NPWT) at 75 mm Hg can expedite wound healing and improve skin graft survival. Has been shown in case report to be safe in the periocular area, with no long-term effect on vision or intraocular pressure (IOP). IOP should be monitored while on NPWT (Semlacher, OPRS 2012).
Hyperbaric oxygen therapy has been shown to decrease mortality and increase tissue viability in case series (Lazzeri, OPRS 2010; Brown, Am J Surg 1994).
Intravenous immunoglobulin (IVIG) has been found beneficial in case reports and small cases series (Morgan, Curr Inf Dis Rep 2011; Aakalu, OPRS 2009).
Common treatment responses, follow-up strategies
Mortality can be as high as 60%, depending on the causative organism and location of the infection.
Tissue loss due to infection or debridement might require secondary reconstruction with skin grafts, advancement flaps, or other reconstruction techniques (Tambe, Eye 2012).