Role of medial orbital wall decompression in COVID-19-associated rhino-orbital mucormycosis management

Abstract

Dear Editor, The second wave of the COVID-19 pandemic has brought new challenges for ophthalmologists. There has been a surge in cases of rhino-orbital mucormycosis. When there is orbital involvement, proptosis is evident; in addition, there is chemosis, ptosis, limitation of ocular movements, and diminution of vision. Orbital inflammation with an increase in intra-orbital pressure is the primary cause for this. In addition, there is colonization of the orbital apex by the virulent fungus. Eventually, there is loss of vision either due to the inflammation or thrombosis of the arterial supply to the optic nerve. In our series of 111 cases of rhino-orbital mucormycosis, we performed an MRI scan or CT scan in all patients. All the patients were receiving intravenous liposomal amphotericin B, which is fungicidal. All cases underwent functional endoscopic sinus surgery (FESS) and at the time of completion of FESS, the nasal cavity and sinuses were thoroughly debrided and washed. When we noted signs of orbital inflammation or raised intra-orbital pressure, as judged by finger pressure comparing the two eyes or if there were clinical signs such as chemosis, ptosis, ocular movement limitation, or diminution of vision, we performed an endoscopic removal of the ethmoid bone completely, thus exposing the periorbita and made two cuts in the periorbita, above and below the medial rectus muscle anteroposteriorly and allowed orbital fat to prolapse into the sinuses. Thirty-six patients underwent this medial orbital wall decompression, and none needed orbital exenteration. Postoperatively, there was an improvement of the ptosis, and ocular movements, resolution of the chemosis, and vision was maintained or improved in all patients [Fig. 1]. Five patients had no light perception at presentation and vision did not improve in them. There was no recurrence at the 3-month follow-up. MRI scan shows enlarged extraocular muscles in most cases with pressure on the optic nerve and this surgical maneuver relieves this pressure. This surgical step is commonly performed in cases of thyroid eye disease where there are signs of inflammation and increased intra-orbital pressure.[12] We recommend performing this surgical procedure along with FESS as needed, as this is effective in preventing unsightly proptosis with loss of vision and thus obviates the need for exenteration.Figure 1: A 52-year- old lady, presented on the tenth day, post COVID-19 infection, with right eye pain, swelling and diplopia. She had chemosis, limited ocular movements, lid edema and proptosis. (a). Following medial orbital wall decompression with institution of intravenous Amphotericin B, the chemosis, diplopia and proptosis resolved, as seen in the 3-week postoperative picture (b). MRI scan (c) T2 coronal and (d) T1 axial scan shows sinusitis involving the ethmoid and maxillary sinuses at the time of presentationDeclaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.