Orbit management sans exenteration with retrobulbar injection of amphotericin-B in Rhinoorbitocerebral mucormycosis: Impact on survival

Abstract

Purpose

This study aims to describe the impact on survival of non-exenteration management of orbital disease, supplemented with transcutaneous retrobulbar injection of amphotericin B (TRAMB), in a cohort of patients with COVID-19-associated ROCM, a life-threatening condition for which exenteration is generally the preferred treatment modality.

Method: This retrospective cohort study included 69 COVID-19-associated ROCM patients. All patients were treated with intravenous liposomal amphotericin-B and surgical debridement of paranasal sinuses. All patients with orbital disease were treated with TRAMB (42/69); orbital debridement or extended enucleation was performed when the disease was severe or progressive; debridement of intracranial disease was done when indicated.

Results

Of the 69 patients included, at discharge, 45/69(65.2%) had cured/stable ROCM, 13/69(18.8%) died and 11/69(15.94%) were discharged on request, with progressive disease. The vision was preserved in 45/69(65%), a blind eye with preserved ocular globe in 18/69(26%), and 6/69(9%) underwent extended enucleation. At 18 months follow-up, 6/56 died, 13/56 were lost to follow-up and 37/56 were alive. The cumulative mortality was 27% (19/69). Independent risk factors for mortality were increasing age(p = 0.003), diabetic ketoacidosis(p = 0.006), severe COVID-19 (p = 0.04), and CNS involvement (p = 0.01).

Conclusion

In this study, conservative orbit management sans exenteration augmented with retrobulbar injection of amphotericin B was an effective treatment modality for orbital involvement in ROCM. The mortality in our patients was comparable to reports where exenteration was the first line of treatment, with better vision and cosmetic outcomes. Further studies comparing orbit conservation with TRAMB versus exenteration may be needed to delineate further, whether this approach can be an alternative to exenteration.