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Orbital exenteration is a radical surgery reserved for the treatment of locally invasive or potentially life‐threatening orbital tumours.1 Complications occur after 20–25% of exenterations and include tissue necrosis (6%) and infection (3–4%).2,3,4 In the present report, we describe the management of a post‐exenteration orbital infection by the use of maggots.
An 82‐year‐old multimorbid man presented with a fist‐sized painless tumour of the left orbit (fig 1A1A).). Computed tomography demonstrated an orbital mass clearly demarcated from the surrounding tissue (fig 1B1B).). After biopsy, the neoplasm was classified as a borderline‐malignant extrapleural solitary fibrous tumour. Therefore, a total orbital exenteration was performed, and the wound was left open to heal by granulation. Postoperatively, the patient's general condition worsened because of an infection of the urinary tract and a transient ischaemic attack. In addition, orbital wound secretion became purulent by the twelfth postoperative day despite intensive local disinfection using hydrogen peroxide, treatment with gentamycine ointment, and oral application of ciprofloxacine 500 mg once a day. Microbiological analysis of the wound secretion revealed ampicillin‐sensitive Enterococcus and Bacteroides species. The systemic antibiotic therapy was adjusted to intravenous application of ampicillin 1.2 g three times a day. Nevertheless, no reduction of the purulent secretion was observed. As the patient did not qualify for surgical debridement because of his poor general condition, we decided to place a small envelope of nylon gauze with 50 blowfly maggots (Lucilia sericata, BIOBAG 50; BioMonde GmbH, Barsbüttel, Germany) into the orbit (fig 22)) while continuing systemic antibiotic therapy. Within this biobag the larvae come into contact with the wound fluids but they cannot escape. When the bag was replaced by a new one four days later, almost no purulent secretion was seen. By this time, maggots had grown from 3 mm to approximately 10 mm in size. After a second larval application of four days, the orbit was free of purulent secretion. To prevent new infection, wound treatment was continued by the local application of azidamfenicol ointment two times a day.
Advanced age, multimorbidity, and drug‐resistant bacteria are increasing challenges to wound care. Therefore, alternative ways for debridement and for the management of local infections in addition to the administration of antibiotics are helpful. Clinical observations provide evidence that maggots applied to wounds remove necrotic tissue, promote disinfection, and accelerate granulation tissue formation.5 The larvae ingest microorganisms and destroy them during their passage through the digestive tract.6 In addition, the excretions/secretions released by maggots exert antimicrobial effects and induce fibroblast migration.7,8 So far larval debridement therapy has proved successful in a variety of non‐healing skin and soft tissue wounds, e.g. neuropathic and ischaemic foot ulcers.9 To our knowledge, however, this is the first report on the medical use of maggots in an ophthalmic patient. Potential complications of larval therapy, such as pain, pressure‐induced ischaemia, and patient anxiety can be prevented by analgesics, spacious wound dressings, and patient education.10 None of these adverse effects was observed in our patient. The present case suggests that maggot therapy is a low‐invasive, efficient and cost‐effective option for the treatment of postoperative orbital infections in patients not responding to antbiotic therapy and not qualifying for surgical debridement.
Competing interests: None.
Informed consent was obtained for publication of the figures.