a 25-year - old systemically healthy male patient presented 
 with complaints of severe photophobia , redness , discharge , 
 pain and severe swelling of the lids in the left eye , since two 
 days .
past history was significant for a boil on the lower 
 eyelid , two days ago . on examination , the best - corrected 
 visual acuity was 20/20 and 20/30 , in the right and left eyes 
 respectively .
the 
 left eye showed severe lid edema with scales on the skin and 
 associated kerato - conjunctivitis [ fig .
photographic documentation 
 of the anterior segment condition was impossible because of 
 the severe photophobia .
a conjunctival swab and a periorbital skin swab were sent 
 for culture and sensitivity .
the 
 patient was seen by our infectious diseases expert and started 
 on intravenous co - amoxiclav ( augmentin , glaxosmithkline ) 
 1 g twice daily , intravenous ceftriaxone ( ceftriaxone sodium , 
 sandoz , novartis ) 1 g twice daily and oral metronidazole 
 ( flagyl , searle ) 500 mg three times daily , pending sensitivity 
 reports .
topical loteprednol etabonate ( 0.5% ) ( alrex eye drops , 
 bausch and lomb incorporated ) every three hourly and 
 ciprofloxacin ( 0.3% ) ( ciplox eye drops , cipla ) six times a day 
 were started , in the left eye . on follow - up two days later ,
the skin scabs had fallen off , revealing violaceous , 
 sub - epidermal necrosis .
the conjunctival inflammation had 
 reduced and the corneal marginal infiltrates had almost 
 disappeared [ fig .
the culture plates for corneal infiltrates showed negative 
 growth and were discarded after three weeks .
five days later , the skin lesions had healed and the 
 conjunctivitis had resolved .
intravenous antibiotics were 
 stopped and the patient was started on oral co - amoxiclav 
 ( augmentin , glaxosmithkline ) , 625 mg thrice a day , for a 
 week . on final follow - up a month later , periocular skin discoloration 
 was the only sequalae noted [ fig . 2 ] .
infections in the periocular region occur post surgical 
 procedures , post trauma , furunculosis or even without any 
 antecedent cause.2 ideally , a combination of intensive parenteral antimicrobial 
 therapy and prompt surgical debridement of necrotic tissue 
 should be done .
intravenous pooled immunoglobulin and 
 heparinization may also have beneficial roles by neutralizing 
 super - antigen activity and aiding antibiotic perfusion.4 necrotizing fasciitis is a clinical diagnosis .
necrotizing 
 fasciitis limited to the eyelids looks and behaves differently 
 from nf affecting other parts of the body , due to the excellent 
 blood supply in the eyelid area.3 mild cases , especially those 
 restricted to the eyelids alone may respond to medical therapy . 

the increased blood supply allows for delayed debridement , 
 because the local vasculature allows for better access of 
 the systemic antibiotics to the infected area .
the marginal 
 zone of tissue surrounding the infected area has better 
 local blood supply and hence a higher chance of avoiding 
 necrosis.3 we report the case of a 25-year - old male patient who presented 
 with periocular nf associated with kerato - conjunctivitis . 

the paucity of literature 
 regarding this entity , in association with staphylococcus - induced 
 periocular nf probably stems from an under - reporting bias . 

these infiltrates are usually the result of an immunological 
 reaction with staphylococcal antigens but in cases with severe 
 infection as in our patient , the infiltrates need to be cultured for 
 an infectious etiology .
the patient responded to conservative 
 medical management with systemic antibiotics , topical antibiotics 
 and topical steroids .
we report this case to highlight the successful 
 conservative management of periocular nf and the hitherto 
 unreported anterior segment involvement .
 we report a 25-year - old systemically healthy male who presented 
 with periocular necrotizing fasciitis ( nf ) in the left eyelid . 
 this 
 was associated with the presence of immunologically mediated 
 marginal kerato - conjunctivitis , in the same eye . 
 this potentially 
 dangerous lid infection and the associated ocular surface infection 
 resolved successfully , with medical management . 
 we report this 
 case to highlight the successful conservative management of 
 periocular nf and the hitherto unreported anterior segment 
 involvement . 
Case Report
Discussion