Periocular necrotizing fasciitis following retrobulbar injection

Necrotizing fasciitis is a rare, rapidly progressive severe bacterial soft tissue infection with a high mortality rate. While necrotizing fasciitis classically involves the trunk, groin/perineum, lower limbs, and postoperative wound sites, primary involvement of the eyelids is a rare but well known entity. We present a 33-year-old female patient who developed periocular necrotizing fasciitis after local retrobulbar anesthesia injection and facial block for cataract surgery in the left eye and canthotomy/cantholysis for treatment of moderate retrobulbar hemorrhage in the same eye. Surgical debridement was done and necrotic foul-smelling eyelid and deep orbital tissues were removed, and culture grew Staphylococcus aureus. Despite initial surgical debridement and intravenous antibiotic therapy, the disease progressed rapidly; orbital exenteration was considered, but the patient declined the surgery and self-discharged. Periocular necrotizing fasciitis remains predominantly a clinical diagnosis, and is often missed early in its presentation because of the difficulty in distinguishing it from other common soft tissue infections, especially in the presence of surgical wounds and retrobulbar hemorrhage. A high index of suspicion, early recognition, and prompt therapeutic interventions are indispensable for optimal visual outcome and patient survival.