Periocular necrotizing fasciitis following retrobulbar injection
A 33-year-old female patient presented to the eye clinic at Jimma University Hospital with bilateral painless progressive loss of vision, and on examination was found to have bilateral presenile cataract, so was admitted to the eye ward to have left eye cataract extraction. On the following day, she underwent standard preoperative preparation of the left eye and was taken to the operating theater. The left eyelid and periorbital area were cleaned with 70% alcohol. During retrobulbar injection of 4 mL of lidocaine hydrochloride 2% and epinephrine 1:100,000, she developed moderate retrobulbar hemorrhage which warranted cancellation of the planned cataract surgery. Tubicort® (Tubilux Pharma S.p.A, Rome, Italy) (hydrocortisone 0.5% + oxytetracycline 0.9%) eye suspension was instilled and the eye was patched. She was given a 500 mg oral loading dose of acetazolamide and a maintenance dose of 250 mg qid, and sent to the eye ward for bed rest and follow-up.\nOn the next day, she had diffuse, warm, tense, and tender reddish blistering eye lid swelling associated with headache and periorbital pain, but her body temperature was normal. With the impression of severe retrobulbar hemorrhage, lateral canthotomy and cantholysis were done to relieve the pressure, and she was given paracetamol 1 g tablets as required and continued acetazolamide. However, the globe was still tense. Hence, surgical evacuation of orbital hematoma through anterior orbitotomy was attempted but no significant hematoma was found. Post-orbitotomy, intravenous cloxacillin 500 mg qid and ceftriaxone 1 g twice daily was started. Chloramphenicol eye ointment was applied twice daily. Vital signs were stable (pulse rate 90 per minute, respiratory rate 16 per minute, temperature 36.5°C, blood pressure 90/70 mmHg).\nOn subsequent days (3 and 4), the upper and lower eyelids of the left eye and the surrounding face became blue-gray and necrotic, with loss of touch and pain sensation over the swelling and around it (). The patient was unable to open the lid, so visual acuity was not measured. At this stage, necrotizing fasciitis was considered and intravenous metronidazole was added.\nOn day 5, surgical debridement was done and necrotic foul-smelling tissues over the upper lid, lower lid, and deep orbital tissue under the lateral canthus were removed (). A specimen was sent for culture which grew S. aureus. Other hematological and serological tests (for fasting blood sugar, white blood cell count with differential, erythrocyte sedimentation rate, and venereal disease research laboratory and human immunodeficiency virus) were unrevealing.\nIntravenous cloxacillin, ceftriaxone, and metronidazole, as well as daily wound care and dressing with Furacin® (Universal Twin Labs, Mumbai, India) ointment was continued but there was no improvement. On day 13, redebridement was done; at this time, the bulbar conjunctiva, sclera, and orbital tissue were necrotic and vision was no light perception. The clinical decision for orbital exenteration was taken and discussed with the patient and her family, but she declined and self-discharged against medical advice and repeated counseling, and did not return for further follow-up.\nThe patient had no previous or current nasal discharge, history of trauma, previous facial/nasal/ocular wound, known drug allergy, history of drug usage, or personal or family history of known systemic diseases (diabetes mellitus, hypertension, or cardiac, renal, or liver disease).