Mentions: After 48 hours on antibiotics, only minimal improvement in swelling was noted (Figure 1A); she continued to report a significant amount of pain. A repeat CT of the orbit with contrast (Figure 2A) showed significant worsening of the left sided orbital cellulitis with interval development of a large abscess of the left eyelid and lateral orbit that extended into the extra-conal space. It also showed left-sided proptosis and straightening of the left optic nerve. On examination, the patient had progressive worsening swelling and pain. Clinical suspicion for NF was high; therefore, she was taken to the operating room emergently for incision and drainage by the oculoplastic surgery service. Using a lid crease incision, the upper eyelid and superior orbit were extensively explored. Cheesy, white, necrotic-appearing tissue was noted (Figure 1B). A small amount of pus was drained from the upper eyelid. A Penrose drain was placed, and the incision was loosely closed (Figure 1C). Postoperatively, wound culture returned positive for methicillin-resistant Staphylococcus aureus (MRSA). After consultation with the infectious disease (ID) service, her antibiotic therapy was narrowed to vancomycin alone. After 36 hours of careful observation, lid and facial edema showed no improvement and continued to have significant areas of induration. She was taken back into the operating room for another debridement. The lid crease incision was reopened and a canthotomy and cantholysis were performed to gain greater exposure. The superior orbit, the upper lid, and the tissues lateral to the lateral canthus were explored. Fibrous white tissue was noted in the superior and lateral orbit, and also in the subcutaneous layers temporal to the lateral canthus. This tissue was avascular and did not bleed when incised; much of it was debrided. Surgical pathology specimens were sent from the superior orbit, the orbital septum, preaponeurotic fat, and temporalis fascia; all were found to be fibrous. The hematoxylin and eosin stain noted marked acute inflammation and focal necrosis (Figure 2B). A second Penrose drain was placed. Finally, a partial tarsorrhaphy was placed to protect the ocular surface.
Patient: female, 60"/>