Complete Ophthalmoplegia Research Articles

Rapidly Developing and Elusive Rhino-Orbital-Cerebral Mucormycosis

Purpose: To report a case of rapidly progressing rhino-orbital cerebral mucormycosis that was particularly difficult to diagnose, initially presenting as orbital apex syndrome. Major findings: In this case, a 59-year-old male patient with uncontrolled diabetes presented with a history of facial pain with no ocular involvement. Within 1 day of hospitalization, the patient developed complete ophthalmoplegia and total visual impairment of the right eye. Over the course of 2 hospital stays, several biopsies resulted in no significant histopathological findings, and several cultures resulted in growth of only a single colony of rhizopus mucor from the sinonasal mucosa. Given the high clinical suspicion of an invasive fungal infection, a universal PCR test was performed from a rapidly developing abscess in the frontal lobe and confirmed a diagnosis of mucormycosis. Conclusions: Orbital apex syndrome is a significant diagnosis that can be caused by a variety of factors, including those of fungal, bacterial, neoplastic, or inflammatory origin. Fungal infections, are a particularly concerning cause of orbital apex syndrome, given their ability to penetrate in and through the orbit to the brain, often resulting in an alarmingly high mortality rate. Mucormycosis, specifically rhino-orbital cerebral mucormycosis, is a very severe opportunistic invasive fungal infection, most often afflicting the immunocompromised. A clinician must be very thorough in their workup so as to not miss such a devastating diagnosis. Histopathology and cell cultures are currently the gold standard for diagnosis, with the potential to augment their technical success through the use of molecular techniques, such as universal PCR.

Orbital Apex Syndrome Caused by Invasive Fungal Sinusitis due to Candida glabrata: A Case Report

Purpose: To report a case of orbital apex syndrome resulting from invasive fungal sinusitis attributed to the unusual <i>Candida glabrata</i> species.Case summary: A 76-year-old patient presented with persistent left-sided orbital pain, headaches, and blurred vision for 3 weeks. The patient had a history of uncontrolled diabetes, chronic kidney failure, and angina, and was treated for a COVID-19 infection 1 month prior to admission. Contrast-enhanced computed tomography scans revealed extensive bilateral sinusitis affecting the left optic nerve. The patient underwent endoscopic sinus surgery, which included nasal cavity biopsy, conducted by an otorhinolaryngologist. Histopathological analysis using Gömöri methenamine silver stains identified <i>Candida</i>. Cultures from sinus specimens later grew <i>Candida glabrata</i>. Treatment involved daily IV amphotericin B followed by oral itraconazole. After 6 months, the patient fully recovered from fungal sinusitis but continued to experience negative light perception in the left eye and progressed to complete ophthalmoplegia, consistent with orbital apex syndrome.Conclusions: Reports of invasive fungal sinusitis caused by <i>Candida</i> infections are rare globally. This report marks the first occurrence in this country. Effective management requires careful assessment and appropriate treatment tailored to the specific species, especially considering the risk of orbital extension of the inflammatory lesion.

Fisher Syndrome

Fisher syndrome is recognized as a variant of Guillain-Barré syndrome, encompassing acute onset immune-mediated neuropathies marked by the classical triad of ataxia, areflexia, and ophthalmoplegia. Generally, Fisher syndrome follows a self-limited course with a good prognosis. Ophthalmoplegia, typically bilateral, progresses to complete external ophthalmoplegia within 1-2 weeks. Ataxia, often very severe, may cause an inability to walk without support despite normal strength. Fisher syndrome is also frequently concomitant with additional clinical features, including ptosis, internal ophthalmoplegia, facial nerve palsy, sensory deficits, and bulbar palsy. The confirmation of an antecedent infection is often established. Among the ganglioside antibodies, anti-GQ1b antibodies exhibit positivity in over 80% of patients. The syndrome manifests in three distinct types: a partial subtype exhibiting only a subset of the triad symptoms, Bickerstaff's brainstem encephalitis marked by impaired consciousness and pyramidal tract signs, and an overlapping subtype with Guillain-Barré syndrome, characterized by weakness in the extremities.

Tolosa Hunt Syndrome: An Atypical Presentation of a Rare Condition

Abstract Purpose: Tolosa-Hunt Syndrome (THS) is a rare disorder with signs and symptoms that mimic various other diseases. Diagnosis of THS, especially in atypical cases, can be challenging due to the need to exclude other diseases. Observations: A 59-year-old-male presented with acute vision loss of his left eye preceded by acute worsening of chronic headaches. Additionally, he had near complete ophthalmoplegia of this eye. He underwent extensive workup including numerous hematologic studies, cerebrospinal fluid studies, and neuro-radiological imaging studies. All tests had normal results except for an elevated ESR of 92 mm/hour and an abnormal MRI of the brain and orbits. The MRI revealed the left orbit as abnormal with proptosis and intraconal inflammatory change. It also showed abnormal enhancement of the left orbital apex and adjacent lateral aspect of the left sphenoid sinus. He was diagnosed with THS and rapidly responded to corticosteroid treatment. Conclusions and Importance: THS can be challenging to diagnose because it is a diagnosis of exclusion. An added difficulty with THS is the need to quickly recognize and diagnose it since early treatment with corticosteroids can produce a rapid treatment response and decreases the chance of severe residual symptoms. THS does not usually affect the optic nerve, but optic nerve damage can occur and involvement of the optic nerve further increases the urgency of diagnosing it and promptly initiating treatment.

Complete Ophthalmoplegia as a Rare Manifestation of Artery of Percheron Infarction: A Case Report & Current Review (P8-10.003)

Complete Ophthalmoplegia as a Rare Manifestation of Artery of Percheron Infarction: A Case Report & Current Review (P8-10.003)

Ptosis revealing breast carcinoma about a case

Aims/Purpose: The purpose of our work is to describe the clinical and therapeutic aspects of a clinical case of ptosis revealing breast carcinoma.Methods: We report the case of a 61‐year‐old patient, with no pathological history, who presented to the ophthalmological emergency department for a unilateral left ptosis, of rapidly progressive onset.Results: This is a 61‐year‐old patient, with no pathological history, who presents to the ophthalmological emergency department for a unilateral left ptosis of rapidly progressive onset. Ophthalmological examination noted visual acuity at 10/10 in 2 eyes and Parinaud 2 in near vision in 2 eyes, complete ophthalmoplegia of oculomotor nerve (III) with severe ptosis on the left and relative left afferent pupillary deficit. The ophthalmological examination of the right eye was unremarkable. The general examination revealed a right breast mass. Cerebral angio‐MRI revealed four metastatic lesions on the left, above and under tentorial. A mammography showed a diffuse invasive lesion classified ACR 5 (American College of Radiology) on the right. A breast biopsy with histopathological study confirmed the diagnosis of poorly differentiated and invasive lobular carcinoma of the right breast. The patient is currently undergoing chemotherapy treatment.Conclusions: Acute ptosis is an emergency. Thus, a well‐conducted interrogation as well as a thorough general and ophthalmological examination make it possible to orient the etiological assessment and to take early and adequate management of a pathology that may be life‐threatening for the patient.

Complications of a Giant Cavernous Carotid Artery Aneurysm

Cavernous carotid aneurysms (CCAs) differ from other intracranial aneurysms in that most are asymptomatic and are generally considered benign as there is a low risk of rupture. More common than complications from rupture are complications from the mass effect of the aneurysm itself on nearby structures.1,2 This report describes a case of a giant right CCA that progressed in size despite multiple surgical repairs that resulted in near- complete ophthalmoplegia and neurotrophic keratitis which led to a perforated corneal ulcer and subsequent enucleation.

Atypical orbital primary optic nerve sheath meningioma with severe disfiguring proptosis: an alternative surgical approach

Primary optic nerve sheath meningioma is generally a benign tumor. In rare instances, however, the growth rate and intraocular and intracranial extensions can be highly aggressive, especially in children, leading to poor prognosis. Here, we reported a case of a 24-year-old woman who presented with left eye swelling for 3 years. This was associated with blurred vision, retrobulbar pain, and redness. On examination, the left eye was severely proptosed with complete ophthalmoplegia. Magnetic resonance imaging showed an extensive tumor occupying the whole left orbital cavity with a disfigured eyeball. However, no intracranial extension was observed. Interestingly, complete surgical excision was feasible via transconjunctival anterior orbitotomy without bone removal. The histopathological examination confirmed the diagnosis of optic nerve sheath meningioma. Adjunct radiotherapy was given. On a follow-up after 2 years, left enophthalmos with esotropia was observed.

SAT058 Diabetes Complicated By DKA, Mucormycosis And Covid-19

Abstract Disclosure: A. Gordon: None. Background: Mucormycosis is an invasive opportunistic fungal infection, that although rare, has an estimated all-cause mortality of 54%. Even with aggressive treatment, significant tissue necrosis and bone destruction can occur. Risk factors include diabetes, acidosis (as in diabetic ketoacidosis), excess iron, transplant, malignancy, kidney and liver disease, immunosuppressant and corticosteroid use - and in more recent times, the Covid-19 infection. We present a case of invasive rhino-orbital cerebral mucormycosis in the setting of DKA, uncontrolled diabetes and Covid-19. Case: A 60-year-old female with history of uncontrolled type 2 diabetes (HbA1c 14.3%) presented after being found unresponsive. Her exam was significant for encephalopathy, complete left eye ophthalmoplegia and right-sided hemiparesis. She was hemodynamically stable without fever. Initial labs showed significant hyperglycemia with an elevated anion gap and beta-hydroxybutyrate indicative of diabetic ketoacidosis (DKA). She had a lumbar puncture which showed leukocytosis with neutrophilia (146 WBC, 39% neutrophils), elevated glucose and normal protein; CSF culture was negative for growth. She also tested positive for Covid-19 although CXR was unremarkable and she did not require treatment. Initial CT/CTA head/neck showed complete occlusion of the left cervical internal carotid artery with associated acute/subacute infarcts in the left frontal, parietal, temporal and occipital lobes. CT sinuses showed severe frontal, maxillary and ethmoid sinus mucosal wall thickening with left premaxillary soft tissue swelling and leftward nasal septum deviation. Finally, orbital imaging showed left cavernous sinus thrombosis, left superior ophthalmic vein thrombosis, and necrosis vs devascularization of the extraocular muscles. She was initially treated with fluids, an insulin infusion and broad-spectrum antibiotics and was evaluated by neurology, ophthalmology, infectious disease and otolaryngology. She underwent surgical debridement with left maxillary antrostomy, left total ethmoidectomies and septoplasty. Sinus cultures were positive for MSSA (methicillin sensitive staph aureus) and tissue pathology showed angioinvasive fungal disease compatible with Mucor/Rhizomucor species. Antimicrobial coverage was changed to intravenous Nafcillin and Amphotericin B, and she underwent further surgical debridement twice more. Repeat brain imaging to evaluate for disease progression is pending. Discussion: Early detection and aggressive treatment of Mucormycosis with surgical debridement and Amphotericin B can improve patient outcomes, however the mortality rate is still significant. Therefore, tight glycemic control in high risk groups is imperative, particularly in those with uncontrolled diabetes complicated by DKA and Covid-19 infection (with or without steroid treatment). Presentation: Saturday, June 17, 2023

Bilateral optic neuritis with complete ophthalmoplegia: An extremely rare complication following COVID-19 (Covishield) vaccination

A 35-year-old healthy female presented with decreased vision, headache, painful and restricted ocular movement 5 days following the second dose of coronavirus disease 2019 (COVID-19) (Covishield) vaccination. Her best-corrected visual acuity was 6/36 in both eyes, and color vision was defective. Dilated fundus showed bilateral disc edema. She developed complete ophthalmoplegia 2 days following initial presentation. Imaging studies and systemic investigations were normal. She was treated with systemic corticosteroids. Complete recovery was noted 1 month following presentation. It is critical to raise awareness about the different complication following different COVID vaccinations, but equally important is a timely and justified treatment which would lead to complete recovery.

Orbital infarction during drug abuse: tissues of the globe do not appear to recover function.

To describe the features of an orbital infarction syndrome arising after prolonged orbital pressure during drug-induced stupor in young people. The clinical presentation and course for drug-induced orbital infarction is described, based on a retrospective review of clinical notes and imaging. Two cases of orbital infarction syndrome, due to prolonged orbital compression caused by sleeping with pressure on the orbit during drug-induced stupor, are described. Both patients presented with very poor vision and mydriasis, marked periorbital swelling with some pain, and complete external ophthalmoplegia. Whilst the orbital changes and eye movements recovered, the affected eyes had persistent wide mydriasis, and remained blind with marked optic atrophy. With a mechanism analogous to prolonged orbital pressure due to improper head positioning during neurosurgical procedures, drug-users appear to risk developing an orbital infarction syndrome if they rest with prolonged pressure on the orbit during a drug-induced stupor.

Bilateral Orbital Myositis: A Rare Case Report

The orbital idiopathic myositis is included in the group of orbital inflammatory pseudotumors. It’s an isolated inflammation, unspecific of orbital muscles. This pathology is rare in Children and it is a source of real diagnosis problems. We report the case of a 10-year-old boy who was hospitalized for bilateral painful exophthalmos. We report the case of a 10-year-old boy who was hospitalized for bilateral exophthalmos of abrupt onset, painful, axial, and non reducible with complete ophthalmoplegia of both eyes. The examination showed a retained Visual Acuity (VA) of 10/10 with a normal Fundus Examination (FO) in both eyes. The inflammatory and thyroid work-up are negative. The orbital tomodensitometry revealed a grade I exophtalmitis and a thickening of external and inferior muscles. The corticotherapy leaded to the decline of exophtalmitis andnormalization of eye movements after 1 month of treatment. The etiologic survey was negative, then the diagnosis of idiopathic myositis was kept. The orbital idiopathic myositis stills an eliminating diagnosis. Faced to a child’s exophtalmitis, other differential diagnosis must be excluded by an advanced etiologic survey.

Antivirals vs Antivirals and Steroids for Treatment of Herpes Zoster-Related Ophthalmoplegia: A Case Series and Systematic Review.

Up to 1/3 of patients with herpes zoster ophthalmicus (HZO) may develop ophthalmoplegia. Although zoster-related ophthalmoplegia (ZO) is typically treated with antiviral agents, there is controversy regarding the therapeutic role of systemic steroids. This was a retrospective case series and case report-based systematic review. For the case series, participants were recruited from tertiary neuro-ophthalmology clinics. Eligible participants were those who developed cranial nerve palsies (CNP) within 1 month of HZO diagnosis. In the systematic review, all adults with ZO in the literature who were treated with antivirals or steroids only, or combination therapy were included. Main outcomes were initial presentation, investigations, neuroimaging, treatment regimen, and final outcomes of ophthalmoplegia. Eleven immunocompetent patients with ZO were included. The most common CNP was CN III (5/11), followed by CN VI (2/11) and CN IV (2/11). One patient had multiple CNPs. All patients were treated with antivirals, and 4 also treated with a short course of oral steroids. At 6-month follow-up, 75% of patients treated with combination therapy and 85.7% treated with antivirals alone had complete recovery of ZO. The systematic review identified 63 studies consisting of 76 cases of ZO. When comparing patients treated with antivirals with those treated with antivirals and steroids, patients on combination therapy had more severe ocular findings, including complete ophthalmoplegia ( P < 0.001). Age was the only significant predictor of complete recovery of ophthalmoplegia on multivariable logistic regression ( P = 0.037). The rate of complete recovery in immunocompetent patients with ZO was similar in patients treated with antivirals alone vs those treated with antivirals and oral steroids. The systematic literature review affirmed these findings. However, age may influence recovery of ophthalmoplegia.

Clinical and radiological profile of cavernous sinus syndrome: a study from eastern part of India

BackgroundCavernous sinus syndrome (CSS) consists of a variable combination of involvement of the 3rd-to-6th cranial nerves. The etiologies vary across studies, and it has a significant impact on the outcome. This study was done to delineate the etiology, clinico-radiological profile and outcome of CSS. In this prospective study, patients were recruited consecutively over 2 years, and were followed up for at least 6 months. MRI of the brain and orbit with contrast was done, and other relevant investigations were performed to arrive at a specific etiology. Tolosa-Hunt Syndrome (THS) was defined in accordance with the second edition of the International Classification of Headache Disorders (ICHD-II).ResultsOf the 92 patients studied, THS was the predominant diagnosis, followed by Tuberculosis, fungal infection, aneurysm, neoplastic and Sjögren’s syndrome. Cranial nerves commonly involved were 3rd, 4th, 6th and 5th. The optic nerve was affected in 54.3% of patients. The non-THS patients showed the greater occurrence of proptosis, complete ophthalmoplegia, involvement of optic nerve and cranial nerves 7th–10th. Nasal blockage was present in fungal infection. MRI revealed more frequent involvement of orbit in non-THS cases. Bony erosions, ICA narrowing, intracranial extension and involvement of paranasal sinus were seen in fungal infection and neoplasm. THS patients improved with corticosteroid therapy, although, there was recurrence in 8 patients.ConclusionsTHS and tuberculosis were the most common cause of CSS. Clinical and radiological features were useful in distinguishing among the etiologies. Most of the patients responded to treatment, although, recurrence was seen in THS.

The Many Manifestations of Rhino-Orbital-Cerebral Mucormycosis: An Illustrative Case Report (P10-10.003)

<h3>Objective:</h3> To describe and illustrate with neuroimaging the progression of rhino-orbital-cerebral mucormycosis leading to orbital apex syndrome, cranial neuropathies, cavernous sinus thrombosis, and strokes from internal carotid artery steno-occlusive disease. <h3>Background:</h3> A 67-year old female with uncontrolled diabetes mellitus presented with progressive vision loss in the right eye and right sided facial weakness, associated with fatigue and fevers. She underwent intranasal debridement, and hematoxylin and eosin staining showed broad-based, branching, non-septate hyphae, consistent with mucormycosis. She was treated with antifungals. She sought care again 3 months later, at which point she had no vision in the right eye, and was unable to open or move the right eye. Her examination at this point was notable for no light perception in the right eye with mid-size, unreactive pupil; complete ptosis and ophthalmoplegia of the right eye; and right facial weakness in a lower motor neuron pattern. Magnetic resonance imaging of the brain demonstrated inflammation at the orbital apex, as well as thromboses of the right superior ophthalmic vein and right cavernous sinus. Despite treatment with systemic antifungals and anticoagulation, the patient later developed sudden-onset lethargy associated with a right gaze deviation. She was found to have severe stenosis of the bilateral intracranial internal carotid arteries on cerebral angiogram. Magnetic resonance imaging showed interval development of bilateral deep watershed territory infarcts. <h3>Design/Methods:</h3> NA <h3>Results:</h3> NA <h3>Conclusions:</h3> Mucormycosis is a rare but devastating fungal infection caused by mucormycetes, which are ubiquitous in nature. Most patients with invasive mucormycosis are immunocompromised, classically due to poorly controlled diabetes or hematologic malignancies. Mucormycosis spreads contiguously through the sinuses, and is also angioinvasive. Because the infection typically begins as a rhinosinusitis, the fungus spreads intracranially through direct invasion of the cavernous sinus. This case and the associated imaging illustrates the stepwise progression of mucormycosis due to contiguous spread intracranially. <b>Disclosure:</b> Dr. Trenz has nothing to disclose. Dr. Tetreault has nothing to disclose.

Gastrointestinal carcinoma first presenting as pituitary mass: recognition of a rare case and multidisciplinary approach for the management of pituitary metastases

Abstract Introduction PMs (pituitary metastases) are rare and only a few cases are reported in the literature. In half of the documented cases, PMs originate from breast and lung cancers, rarely from other sites. They can grow rapidly and present local invasiveness, leading to acute onset of neurological symptoms, such as headache, visual and oculomotor disturbances, or endocrinological signs, such as diabetes insipidus and hypopituitarism. Their rarity and the lack of specific clinical and radiological features often impede their differentiation from other more common sellar area lesions, particularly when history of malignancy is absent. As PMs can be life-threatening, they must be recognized and treated promptly. Management of PMs may also be difficult because the prognosis depends on the course of the primary neoplasm. The case presented below is one of the few documented cases in the world of a pituitary metastasis from a primary gastrointestinal carcinoma. Clinical Case A 76-year-old woman, with no history of malignancy, presented with headache, dizziness and diplopia. Neurologic examination was remarkable for complete left ophthalmoplegia associated with sensitivity deficit in the left half face. Radiologic investigations documented a voluminous sellar and suprasellar formation, with extension in the ipsilateral cavernous sinus, compressing the optic chiasm and ipsilateral temporal lobe. The mass appeared heterogeneous as component of apoplectic infarction. Left cavernous sinus syndrome in apoplectic macroadenoma was diagnosed. Surgical removal of the lesion was performed through a transsphenoidal endoscopic endonasal approach. The histological exam disclosed a metastasis of adenocarcinoma with widespread necrotic-haemorrhagic elements. The immunohistochemical profile suggested an origin from a primary gastrointestinal carcinoma. Hormone replacement therapy and adjuvant therapy were instituted, although radiological investigations failed to identify the site of the primary gastrointestinal carcinoma. Postoperative MRI showed a parasellar residual tumor, which was radiologically stable at 6-month follow-up. The patient will undergo a radiotherapy and neurosurgical evaluation. Conclusions Clinicians should consider the possibility of PMs in patients with symptoms and signs that may suggest the presence of a pituitary mass. Since PMs can be cancer first manifestation, the recognition of PMs determines the referral to adequate oncological therapy. Prognosis is usually poor and it's difficult to estimate as it varies significantly depending on the systemic disease and the primary histology. Recognition and management of PMs remain complex and require a multidisciplinary team of endocrinologists, oncologists, neurosurgeons and neuroradiologists.

Clinical Features and Differences of Miller Fisher Syndrome in Southern China: Retrospective Analysis of 72 Patients in 13 Provinces of Southern China.

We aimed to determine the clinical features of Miller Fisher syndrome (MFS) in southern China and compare them with those presenting in other countries. We collected the medical records of patients diagnosed with MFS during 2013-2016. We analyzed the age, sex, onset season, precursor events, clinical symptoms and signs, findings of nerve conduction studies (NCS), cerebrospinal fluid (CSF), therapeutic remedies, nadir time, and length of hospital stay of patients with MFS in southern China. We concurrently compared the differences between urban and rural areas and between patients with incomplete ophthalmoplegia (IO) and complete ophthalmoplegia (CO). The study enrolled 72 patients: 36 from rural areas and 36 from urban areas, and 50 males and 22 females. The mean age at onset was 47.72 years, and 30 (41.7%) and 21 (29.2%) patients developed MFS in spring and winter, respectively. The typical triad of ophthalmoplegia, ataxia, and areflexia was observed in 50 (69.4%) patients. A history of upper respiratory tract infection 1 week before onset was found in 52.8% of the patients, while 5.6% experienced gastrointestinal infections and 48 (73.8%) exhibited albuminocytological dissociation in the CSF study. Only 26 (36.1%) patients presented abnormalities in NCS. Moreover, restricted outward eyeball movement presented in 83.5% of the patients with classic MFS and acute ophthalmoplegia, and bilateral symmetrical ophthalmoplegia presented in 64.2%. With the exception of the higher proportion of NCS abnormalities in urban areas (47.2% vs. 25.0%), urban and rural differences were insignificant regarding sex ratio, age at onset, high-incidence season, precursor events, disease characteristics, and albuminocytological dissociation in the CSF. Furthermore, patients with CO were older than those with IO (64.53±7.69 vs. 43.19±14.40 years [mean±standard deviation], p<0.001). The patients with MFS were mostly male and middle-aged, and most presented in winter and (especially) spring. More than half of the patients had clear precursor events, most of which were classic MFS with the typical triad. More than 70% of the patients presented albuminocytological dissociation in the CSF. NCS abnormalities were uncommon in MFS. The age at onset was lower in patients with IO than in patients with CO; bilateral symmetrical extraocular muscle paralysis was the most common symptom, and the external rectus was the most frequently involved muscle.

Reversible Brain Death

Snakebite is a serious public health problem and one of the priorities in WHO's list of neglected tropical diseases. It significantly increases morbidity and mortality associated with envenomation in India. A neurotoxic snakebite can present in the form of symptoms ranging from asymptomatic presentation, ptosis, and complete external and internal ophthalmoplegia to complete respiratory failure. This is a case report of a 22-year-old male, who presented with bilateral ptosis and impending respiratory failure. He soon became deeply comatose, with absent brain stem reflexes (mute plantar, fixed pupils, and the absence of the doll's eye reflex) which were suggestive of brain death. He was treated with polyvalent anti-snake venom, anticholinesterases, and supportive therapy and recovered completely with an excellent outcome.

Risk Factors of Rhino Orbital Mucormycosis.

To determine the clinical presentation and risk factors associated with rhino orbital mucormycosis. Mucormycosis is a rapidly progressive fungal infection caused by filamentous fungi in the Mucoraceae family. In large numbers, they release spores into the air, and humans get exposed through inhalation. The spores inoculate in the paranasal sinuses and nasopharynx and subsequently spread to the orbit and intracranial cavity. The present COVID-19 pandemic has witnessed a resurgence of rhino-orbital mucormycosis cases, mainly seen in patients with immunocompromised status. Hence, our study evaluated the risk factors and clinical features of rhino orbital mucormycosis. This was a prospective, single-center, cross-sectional study. Patients attending tertiary care centers fulfilling the inclusion criteria were evaluated with a detailed history including sociodemographic profile, occupation, history of fever, COVID-19 infection, steroid or immunosuppressant use, organ transplants, diabetes mellitus and use of oxygen (O2). A complete ophthalmic evaluation was performed, including best-corrected visual acuity, anterior segment evaluation with slit lamp biomicroscopy, and posterior segment evaluation using indirect ophthalmoscopy. Computed Tomography (CT) scan of paranasal sinuses was done for all the patients, and Magnetic Resonance Imaging (MRI) for a few patients if indicated. Intraoperatively, samples were sent for Potassium Hydroxide (KOH) stain while debridement and patients with positive results were included in the study. Forty participants were included, out of which 34 (85%) were males and six (15%) were females. The mean age of the patients was 51.75 years. Out of 40 patients, 29 (72.5%) had h/o COVID-19 infection, 30 (75%) were known type 2 diabetes mellitus, 25 (62.5%) had a h/o steroid intake and 25 (62.5%) had a history of O2 use. 17 (42.5%) patients presented with low vision, out of which 15 had no light perception. 30 (75%) patients had ptosis, 22 (55%) patients presented with proptosis, 15 (37.5%) patients had limited ocular motility, 11 (27.5%) had complete ophthalmoplegia, and 11 (27.5%) patients had central retinal artery occlusion. Rhino orbital Mucormycosis is more prevalent in patients with COVID-19 infection, especially those who have used steroids and oxygen and with type 2 diabetes mellitus. Early presentation with treatment can prevent further ocular morbidity.

Orbital apex syndrome in rhino-orbito-cerebralmucormycosis (ROCM) – A prospective observational study

Orbital apex syndrome (OAS) is an uncommon clinical presentation consisting of complete ophthalmoplegia with vision loss, involving cranial nerves II, III, IV, V, and VI. OAS may result from trauma, malignancy, infection, inflammation, or vascular origins. Aims of the study were to analyse the incidence and presentation of orbital apex syndrome in rhino-orbital mucormycosis in a tertiary care hospital. A total of 29 cases (4.1%) out of 696 cases of invasive ROCM with OAS as a presenting feature were documented. Amphotericin B in both retrobulbar and intravenous routes played a crucial role in arresting the spread of the disease allowing only 8 (27%) cases to show disease progression. FESS if done appropriately with efficient debridement of necrotic infective tissue can be a powerful tool in redirecting the course of disease for the better (only 2 of 8 patients with CST at the time of presentation had a history of FESS done prior. ROCM is a severe, emergent and fatal infection requiring multidisciplinary management. It may often present with OAS initially. Mucormycosis must be considered in such patients and timely aggressive management must be initiated to avoid disastrous morbidity and mortality.