Periocular necrotizing fasciitis following external hordeolum: A rare case report

External hordeolum is a common, usually self-limiting eyelid infection that may occasionally progress to preseptal cellulitis. Progression to periocular necrosis and necrotizing fasciitis is extremely rare. We report a 37-year-old gentleman who presented with progressive blackish swelling around the right eye following an external hordeolum despite prior systemic antibiotic therapy. Best-corrected visual acuity was 6/9 in the right eye and 6/6 in the left eye. Clinical examination revealed periocular edema and necrotic eschar involving the preseptal tissues, with sparing of the lid margins. Anterior segment showed mild conjunctival congestion and chemosis. Magnetic resonance imaging demonstrated preseptal and anterior postseptal inflammatory changes without orbital or intracranial involvement. A diagnosis of periocular necrotizing fasciitis involving the preseptal tissues was made. The patient was treated with broad-spectrum intravenous antibiotics followed by surgical debridement and staged eyelid reconstruction with skin grafting. The graft healed well with preservation of eyelid function. This case highlights that even a benign eyelid infection such as a hordeolum may rarely progress to periocular necrotizing fasciitis and may require early recognition and aggressive multidisciplinary management to prevent orbital and intracranial spread.