A 48-year-old male, with long-standing, poorly controlled diabetes, presented in the emergency department of our hospital with a 5-day history of pain, edema and increased lower and lower left eyelid temperature.
as reported secondary to blunt trauma that conditioned a dermoabrasion of little transcendence initially.
Upon admission, she was assessed by ophthalmology and diagnosed with preseptal arthritis.
Eight hours after admission the patient develops necrotic stenosis in the involved tissue.
During the first day of hospitalization, surgical debridement and debridement of all necrotic tissue were performed.
Material is sent to bacteriological culture, identifying Streptococcus Pyogenes.
According to this result, the patient was evaluated by infection and treatment with Meropenem, Vancomycin, Clindamycin and Amphotericin was initiated.
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During the second day of hospitalization, the patient was assessed by the General Practitioner's Wounds Clinic and negative pressure therapy was initiated, with the aim of continuously decreasing the dead space to 125 mmHg.
This therapy was discontinued 3 days later (on the fifth day of hospitalization) due to progression of erythema to contralateral pemphigus vulgaris.
The patient continued to be treated with physiological solution-based dressings and isodine and covered with alginate patches, a procedure in which the infectious process was controlled.
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After 15 days of hospitalization, the patient was evaluated by Plastic Surgery and a good conjunctival tissue was found, aiming at the loss of the total upper eyelid, partial loss of orbicular muscle and focal elevator (the latter).
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One month after the initial assessment, the patient underwent surgical debridement of granulation tissue until partial closure was achieved, identifying an intact tarsal plate.
Local flaps were used to close defects in the conjunctiva, lateral canthotomy, full-thickness graft in the medial canthus and right musculocutaneous frontal flap, which were fixed to the supero-externe muscle remnant.
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Four weeks later, we performed the sectioning of the ligament and the thinning of the flap, showing that the patient presented frontal locking of the eyelid dependent on the myorrhaphy of the frontal lobe with the remnant
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The patient persisted with a greater volume and eversion of the contralateral orbital ligament. Two months later, we performed a new thinning of the flap and corrected the lagophthalmos by canthopy.
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After 2 years of evolution, the ocular globe was covered with complete closure and consolidation without visual repercussions.
No new surgical treatment was required.
