April 2023

OPHTHALMOLOGY

CASE REPORT: ORBITAL NECROTIZING FASCIITIS DUE TO SEVERE ODONTOGENIC INFECTION

A patient presented to a Northwestern Medicine emergency department with a day-long history of severe eye pain, eyelid swelling and decreased vision (only able to see shadows). The Emergency Department physicians ordered imaging for orbital infection as well as facial sinus and tooth infection. Imaging showed the potential for gas in his orbit, raising the concern for necrotizing fasciitis, also known as “flesh-eating bacteria.”
 
Ophthalmology, Infectious Disease, ENT, and Dental Service clinicians at Northwestern Medicine promptly saw and evaluated the patient. Necrotic peri-ocular tissue was sent to Pathology to confirm diagnosis.
 
After confirming the case of necrotizing fasciitis, the team coordinated to immediately institute a broad spectrum of IV antibiotics, as well as surgery. Surgery was a staged multidisciplinary effort with ENT and Ophthalmology undertaking an extensive facial, orbital and sinus debridement. Then, Dental Service extracted the infected teeth. The team believed that the infected teeth were where the infection started before spreading to the sinuses and orbit.
 
When the team explored the orbit, they found purulence and necrosis of orbital structures all the way back to the orbital apex, indicating a very advanced and destructive infection. The patient was admitted to the hospital again for repeat debridement with essential twice daily dressing changes. Northwestern Medicine Plastic Surgery clinicians were consulted, and they made plans to reconstruct the large facial defect that remained by placing an Integra® Dermal Regeneration Template. This allowed the wound to close and helped the patient heal while waiting for further reconstructive procedures.
 
Necrotizing fasciitis of the orbit is rare. It often results in poor outcomes including loss of vision, loss of the eyeball, or even death due to the aggressive, destructive nature of the infection and the surgical debridements needed to stop it from spreading.
 
Thanks to a prompt diagnosis and repeated surgical debridement, the patient’s eyeball was salvaged and they retained their vision, which improved to 20/40 after the surgeries. As a result of the infection, the patient has a large facial defect. Reconstruction is ongoing but they are expected to have a good outcome in terms of eye function and vision.
Preeti J. Thyparampil, MD, is an assistant professor of Ophthalmology at Northwestern Medicine.

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