Seemingly Benign Periorbital Swelling Progressing to Orbital Necrotizing Fasciitis and Sepsis

Document Type

Conference Proceeding - Restricted Access

Publication Date

5-8-2026

Abstract

Orbital necrotizing fasciitis (ONF) is a rare but rapidly progressive infection of the peri-orbital soft tissues that carries substantial risks of vision loss, intracranial extension, sepsis, and death, particularly in immunocompromised patients. Early manifestations may closely resemble preseptal cellulitis, which can delay definitive imaging and surgical management despite a fulminant underlying necrotizing process.

A 79-year-old man with pulmonary fibrosis on chronic corticosteroids, pirfenidone, and Type 2 diabetes initially presented to an ophthalmologist with mild eyelid edema and a normal dilated fundoscopic examination. Within 72 hours, he developed acute confusion, fever, tachycardia, hypoxia, and severe right peri-orbital swelling, prompting Emergency Department evaluation, where examination showed marked proptosis, tense eyelid edema, erythema to the medial canthus, purulent discharge, conjunctival chemosis, and elevated intraocular pressure. Laboratory studies revealed lactic acidosis and leukocytosis, and emergent CT of the head, orbits, and maxillofacial region demonstrated extensive subcutaneous inflammation, a right peri-orbital abscess, retrobulbar fat stranding, and dehiscence of the posterior-lateral wall of the right maxillary sinus.

This case underscores that in immunocompromised or diabetic patients, an initially benign ocular examination does not exclude early ONF, and persistent or rapidly progressive peri-orbital findings should prompt urgent cross-sectional imaging. Early imaging, aggressive surgical source control, appropriate antimicrobial therapy, and coordinated multidisciplinary care are essential to reduce the risks of septic shock, mortality, and long-term functional and cosmetic morbidity in ONF.

Comments

2026 Research Day Corewell Health West, Grand Rapids, MI, May 8, 2026. Abstract 1949

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