Orbital Exenteration Research Articles

Total eyelid complex sparing orbital exenteration for mucormycosis.

Orbital exenteration is a radical surgery which involves complete removal of the orbital contents along with all or parts of the eyelid. However, the eyelid complex can be totally spared in cases of necrotising disease such as mucormycosis without compromising on exposure, or fear of devascularisation of the lids. We describe a total eyelid complex preserving orbital exenteration. Preservation of the total eyelid complex has the potential to speed up the healing process and provide dynamic functional and cosmetic rehabilitation.

Rhino-orbital-cerebral mucormycosis: fungal epidemic in a viral pandemic.

Treatment of coronavirus disease 2019 infection can result in immunosuppression. Rhino-orbital-cerebral mucormycosis is a frequent co-infection, even after recovery. An ambispective interventional study was conducted of 41 coronavirus patients with rhino-orbital-cerebral mucormycosis at a tertiary care centre from March to May 2021. There were 28 males and 13 females with a mean age of 48.2 years (range, 21-68 years). Twelve had long-standing diabetes mellitus and 28 had been recently diagnosed. Thirty-six had received systemic corticosteroids for coronavirus disease 2019. Nasal signs were present in 95 per cent of patients, ophthalmic symptoms and signs in 87 per cent, palatal necrosis in 46.3 per cent, facial signs in 24.3 per cent, nerve palsies in 60.9 per cent, and intracranial involvement in 21.9 per cent. Treatment with amphotericin B was based on clinical features and co-morbidities. Endonasal debridement was performed in 51.2 per cent of patients, total maxillectomy in 14.6 per cent and orbital exenteration in 9.7 per cent. At the last follow up, 37 patients (90.24 per cent) were on antifungal therapy; 4 (9.75 per cent) did not survive. Early detection may improve survival. Follow up of high-risk patients after coronavirus disease 2019 infection is paramount.

Therapy of Uveal Melanoma. A Review

The aim of intraocular melanoma therapy is to achieve local tumor control, reduce the risk of metastasis development, preserve the eyeball and possibly the visual function of the eye. The choice of therapeutic approach requires a comprehensive view and individual approach to each patient with uveal melanoma. Factors considered include local finding (location, tumor size and shape, tumor activity, central visual acuity, intraocular complications), age and the patient‘s overall physical and psychological condition, as well as the patient‘s wishes. The most widely used method of uveal melanoma treatment is radiotherapy. The effect of radiation is caused by the absorption of ionizing radiation energy, the effect of radiation on the cell is manifested by cell death (depletion), or by a cytogenetic information change (mutation). Brachytherapy uses scleral applicators with radionuclide - ruthenium (Ru-106) applicators dominate in Europe and iodine (I-125) applicators in the USA. In external radiotherapy, the source of ionizing radiation is outside the patient‘s body. Both stereotactic radiosurgery and fractionated stereotactic radiotherapy are used. In the Czech Republic, treatment is carried out using Leksell gamma knife or CyberKnife, while proton therapy dominates in the world. The development of serious radiation complications (radiation retinopathy, neuropathy, neovascular glaucoma, toxic tumor syndrome, etc.) should be considered. Surgical therapy involves a variety of invasive procedures. Iridectomy is performed for iris melanoma. Anteriorly located choroidal melanomas and / or ciliary body melanomas can be resolved by transscleral resection (exoresection). For posterior choroidal melanomas, a combination of external tumor irradiation with pars plana vitrectomy is used. Enucleation is a method of choice in advanced tumors that cannot be effectively irradiated. Orbital exenteration is indicated in advanced tumors with extrabulbar spread or in relapsed tumor after previous enucleation.

Mucormycosis, a dangerous complication of covid-19 disease: Documenting the occurrence in Iraq and a review of the literature

Background: Mucormycosis, a rare, but severe angio-invasive disease that can have a catastrophic or fatal outcome. It is an opportunistic infection that has been mostly reported in immunocompromized and diabetic patients, and it commonly begins by invading the respiratory tract. The aim of this paper is to document the emergence of mucormycosis as a dangerous complication of covid-19 in Iraq and many countries in the world.
 Materials and methods: On the first of June, 1,201,352 cases of covid-19 were reported by the Iraqi Ministry of Health, and 16375 patients died because of the disease. During, the first week of June, 2021, the death of Iraqi three patients having covid-19 disease complicated by mucormycosis was reported. At least 140 patients with covid-19 disease complicated by mucormycosis have been reported throughout the world including 100 patients from India, 18 patients from Iran, 11 patients from Turkey, 7 patients from the United States of America, 6 patients from Egypt, 2 patients from Spain, and one patient from each of the following countries, Brazil, Italy, Austria, France, Mexico, UK, and the United Kingdom. Most patients were males and the disease was documented in sixteen females.
 Results: Sino/rhino-orbital mucormycosis with or without cerebral involvement was the most commonly reported type including 87 patients. Pulmonary mucormycosis was the second most common type, and was reported in five patients. Catastrophic outcome occurred in nineteen patients including patients ending with orbital exenteration in patients (14), and patients developed irreversible loss of vision (5). Forty patients with covid-19 with mucormycosis died including, 15 patients from India, eight patients from Iran, seven from Turkey, four deaths from USA, two deaths from Egypt, on death from Brazil, one death from Austria, one death from Mexico, and one death from the United Kingdom.
 Conclusions: Mucormycosis is a rare disease that is generally associated with diagnostic difficulty and delay, high morbidity, catastrophic outcome, and mortality. Diabetes mellitus and use of corticosteroids increase the risk of the development of invasive mucormycosis which may appear during the course of the covid-19, or appear as a later complication. Hyperglycemia induced impaired chemotaxis and phagocytosis of neutrophils, steroid-induced immunosuppression, and covid-19 induced immune dysregulation associated with decreased numbers of T lymphocytes, CD8+T, and CD4+T cells were considered the important factors that led to the emergence of invasive mucormycosis as a catastrophic and fatal complication of covid-19 disease. Mucormycosis can be rapidly progressive, requiring immediate surgical and medical interventions. High index of suspicion can contribute to making an early diagnosis, and providing early aggressive management which can improve survival. Upon suspicion of mucormycosis appropriate imaging is advised to determine extent of disease. First-line treatment is generally including the use of a high-dose liposomal amphotericin B. Other antifungal drugs that have been used include isavuconazole and posaconazole.

Corneal Invasion by Basal Cell Carcinoma.

CASE PRESENTATION A 68-year-old man suffered with a basal cell carcinoma of the right lower eyelid, with features of the morpheaform and nodular types, treated by report with clear margins on Mohs resection and primary closure. Nine years later, an invasive recurrence involved the lateral canthus and lacrimal gland, producing restrictive strabismus. There was no radiographic evidence of orbital invasion. A Mohs resection, clearing the skin and conjunctiva, resulted in an 80% upper and 90% lower eyelid defect, exposing the anterior zygoma and the lateral 180° conjunctival defect (Fig. 1A). However, the region of the lacrimal gland was not cleared by Mohs surgery, and at the time of reconstruction, an intraoperative frozen section of the lacrimal gland demonstrated myoepithelial cells concerning for malignancy, prompting complete resection of the gland. The surrounding orbital fat and soft tissue were histologically clear of tumor. The lower eyelid was reconstructed with a hard palate graft and a myocutaneous advancement cheek flap anchored to the orbital rim. The upper eyelid was reconstructed with advancement of the remnant levator aponeurosis, Müller muscle, and conjunctiva, surfaced with a postauricular skin graft. Postoperatively, a PROSE lens (BostonSight, Boston, MA) was employed to maintain corneal integrity. One year later, the patient developed a second recurrence, treated with vismodegib, which produced clinical and radiographic tumor control but drug intolerance prompted its discontinuation. Eight months later, a third recurrence required re-excision of the tumor, which involved the lateral conjunctiva and extended to the anterior orbit. The area was repaired with a buccal mucosal graft. Globe preservation precluded achieving tumor-free margins. Postoperatively, the patient received 6 cycles of cemiplimab, which failed to suspend tumor progression. He was subsequently treated with sonidegib for a total of 11 months, which also failed to control the tumor, producing a palpable mass in the lower lid, cicatricial ectropion, and an adduction deficit (Fig. 1B). Neuroimaging demonstrated soft-tissue hyperintensity indicative of persistent tumor of the eyelid (lateral canthal infiltration indicated by the arrow) also involving the globe (Fig. 1C). The patient ultimately underwent orbital exenteration. Final pathology revealed invasive basal cell carcinoma, with corneal infiltration (Fig. 1D, E).FIG. 1.: Mohs resection of the initial recurrence of basal cell carcinoma resulted in an 80% upper eyelid defect and 90% lower eyelid defect (A). Following subsequent recurrences and prior to exenteration, a palpable mass was evident in the lower eyelid causing a cicatricial ectropion (B). Neuroimaging revealed lateral canthal infiltration of tumor, as indicated by the arrow (C). Histopathology of the exenteration specimen demonstrated basal cell carcinoma invading the corneal surface (hematoxylin and eosin stain 60× and 600×) (D, E).

Efficacy and safety of retrobulbar amphotericin B injection in invasive fungal rhinosinusitis with orbital invasion patients.

At present, there is no consensus for optimal orbital infection management in invasive fungal rhinosinusitis patients. This is the first retrospective cohort study aimed to determine efficacy and side effects of the retrobulbar amphotericin B injection for orbital management in invasive fungal rhinosinusitis patients. A retrospective chart review was conducted from 2005 to 2020. Thirty-six patients (forty-two orbits) diagnosed with invasive fungal rhinosinusitis with orbital invasion, treated with or without retrobulbar amphotericin B injection, were included in the study. There were a total of 36 patients in the study, 12 patients received retrobulbar amphotericin B injection and 24 did not. There was no significant difference in orbital exenteration and death between two groups. Visual acuity change at the 3rd month was significantly better in the exposure group. There was a significant difference in the overall clinical outcome at 3rd month and 12th month. There was no report of severe side effects in all patients. Retrobulbar amphotericin B injection showed significant efficacy in stabilizing or even improving visual acuity without any side effects. This procedure should be considered as adjunctive treatment.

Rhino-orbital mucormycosis following COVID-19 in previously non-diabetic, immunocompetent patients

ABSTRACT Purpose To report a series of 13 immunocompetent patients who developed new-onset uncontrolled diabetes mellitus (DM) following COVID-19 infection and presented as rhino-orbital mucormycosis (ROM). Method Retrospective study. Results A total of 127 patients of COVID-19 Associated Mucormycosis (CAM) were evaluated at four centres in India. All patients underwent endoscopic sinus debridement surgery and received systemic amphotericin-B therapy. Five patients (5/13; 38.4%) received retrobulbar amphotericin-B injections. Orbital exenteration was performed in advanced orbital involvement or progression of orbital disease in spite of maximal medical therapy. In his cohort, 13/127 (10.2%) patients presented with new onset DM, where one patient had bilateral disease. The mean age was 35.9 years (range: 20–51 years) and the mean duration from diagnosis of COVID-19 to the diagnosis of mucormycosis was 14.2 days. While 7/13 (53.8%) of the patients received systemic corticosteroids during the course of their treatment for COVID-19, six patients received no steroids or immunomodulators. The mean follow-up period was 9.2 weeks (range: 3–18 weeks) following discharge. Life salvage was possible in 100% of the cases. While overall globe salvage was possible in 42.8% (6/14 eyes), the globe could be preserved in 4/5 patients who received retrobulbar amphotericin-B injections. Conclusions Those involved in the care of COVID-19 patients should be aware about the possibility of recent-onset DM, even in patients without a history of corticosteroid therapy. Rarely, recent-onset DM following COVID-19 may present as rhino-orbital mucormycosis, which requires aggressive surgical and medical intervention.

Increased incidence of rhino-orbital mucormycosis in an educational therapeutic hospital during the COVID-19 pandemic in western Iran: An observational study.

BackgroundCOVID‐19 patients, especially the patients requiring hospitalisation, have a high risk of several complications such as opportunistic bacterial and fungal infections. Mucormycosis is a rare and opportunistic fungal infection that mainly affects diabetic and immunocompromised patients. An increase has been observed in the number of rhino‐orbital mucormycosis in patients with COVID‐19 admitted to Imam Khomeini Hospital, Kermanshah, Iran, since October 2020. This is a report of the frequency, risk factors, clinical manifestations, treatment and prognosis of COVID‐19 associated with mucormycosis infection.MethodsThe medical records of COVID‐19 patients with rhino‐orbital mucormycosis who were diagnosed in an educational therapeutic hospital in Kermanshah, west of Iran were surveyed. Several parameters were analysed including demographic, clinical, therapeutic and laboratory characteristics.ResultsTwelve patients with COVID‐19–associated rhino‐orbital mucormycosis were identified from 12 October to 18 November 2020. All cases reported as proven mucormycosis had a history of hospitalisation due to COVID‐19. Comorbidities mainly included diabetes mellitus (83.33%) and hypertension (58.33%). Seventy‐five per cent of patients received corticosteroids for COVID‐ 19 treatment. The sites of involvement were rhino‐sino‐orbital (83%) and rhino‐sino (17%). Amphotericin B/liposomal amphotericin B alone or in combination with surgical debridement or orbital exenteration was used as the first‐line therapy. The overall mortality rate was 66.7% (8/12).ConclusionsWe found a high incidence of mucormycosis among COVID‐19 patients. Diabetes mellitus and corticosteroid use were the dominant predisposing factor of mucormycosis. Mucormycosis is a life‐threatening and opportunistic infection; therefore, physicians should know the signs and symptoms of the disease so that a timely diagnosis and therapy can be performed.

Risk Based Decision Algorithms for Management of COVID-19 Associated Rhino-orbital Mucormycosis.

IntroductionCOVID associated mucormycosis is a challenging problem with significant morbidity and mortality implications. COVID affliction, pre-existing medical conditions especially diabetes and steroid prescription are supposed contributors for development of this opportunistic fungal infection. Surgery remains the mainstay of treatment with adequate post-op anti-fungal therapy.Materials and methodsThis is a retrospective analysis of prospectively maintained database of all surgical patients between March–May 2021 at a single centre. Prognosticators such as severity of COVID affliction, use of steroids, extent of rhino-orbital mucormycosis, extent of surgery and outcomes were studied. Descriptive statistics was used to analyse frequency of different variables and chi square test was used to analyse prognostic factors. P value < 0.05 were deemed significant.Results74 patients with an average 30 day follow-up were included. All patients had preceding COVID infection and 71.6% were diabetic and 25.7% were diagnosed during the course of their COVID treatment. Multiple sinus involvement being most common (52.61%), 10.81% underwent orbital exenteration and 24.32% palatectomies were performed. Revision surgeries were warranted in 16.21% patients. 9 patients succumbed to disease/ underlying medical and treatment related complications.ConclusionWe propose a risk assessment based on general condition of patient and severity of mucormycosis infection to decide appropriate strategy for surgical intervention. Early detection and timely and adequate surgery are essential pre-requisites to good outcomes.Supplementary InformationThe online version contains supplementary material available at 10.1007/s12070-021-02692-9.

Post-COVID-19 rhino-orbito-cerebral mucormycosis: a new addition to challenges in pandemic control.

ObjectiveTo document and analyse demographic data, clinical presentation, possible interventions for early clinical detection and management of post-COVID-19 rhino-orbito-cerebral mucormycosis (ROCM).Method32 patients having history of SARS-CoV-2 infection with features of ROCM were observed in terms of their history, presenting features, clinical, microbiological examination, type of surgical intervention, surgical sites of involvement which were subsequently analyzed.ResultsThe mean (± S.D.) age of patients was 57 ± 13 years. All patients were diabetic. Mean (± S.D.) time of onset of ROCM symptoms, since onset of COVID-19 symptoms was 18 (± 4) days. 12.5% patients were fully vaccinated. 78.1% patients received steroid therapy; 28.1% received high flow nasal oxygen. 87.5% patients had blurring of vision, 65.62% headache, 59.37% cheek and eyelid swelling, 50% proptosis, 46.87% ophthalmoplegia, 40.62% ptosis, 40.62% loss of sensation over cheek, 25% orbital pain. Examination of specimen with KOH mount revealed Mucor spp. in all patients. 87.5% patients underwent endoscopic sinus surgery with debridement with/without orbital clearance; 56.25% maxillectomy; 25% orbital exenteration. 87.5% patients had paranasal sinus involvement, 43.75% orbit sparing orbital apex, 68.75% orbit with orbital apex. 81.25% patients had involvement of pterygopalatine fossa±infratemporal fossa. 50% patients had disease in Vidian canal and pterygoid wedge. 25% of patients had involvement of palate and 56.25% cheek and eyelid soft tissues.ConclusionA judicious COVID treatment protocol, high index of suspicion, close monitoring of high-risk patients and early institution of treatment can prevent case severity and reduce mortality.

The combined coronal–transconjunctival approach: an innovative surgical access for orbital exenteration in craniofacial resection

Malignant tumours arising in the paranasal sinuses or maxilla usually spread to the surrounding regions. The skull base and the anterior cranial fossa are frequently affected as well. When the resection of a tumour involves an orbital exenteration, a transconjunctival-perilimbic incision can be added to a coronal approach in order to preserve the eyelids and the conjunctiva, avoiding cutaneous midfacial incisions. Patients with a diagnosis of malignant tumour affecting the orbit, upper jaw, paranasal sinuses, and/or anterior skull base were eligible for this technique. Tumoural invasion of the eyelids, conjunctiva, lacrimal system, or surrounding skin was considered a contraindication for this technique. A retrospective study of the clinical records was performed and age, type of tumour, location, and reconstructive technique were evaluated. Eight patients referred to the study department between 2015 and 2019 were selected. All patients underwent craniofacial surgery and orbital exenteration. The transconjunctival-perilimbic approach was combined with a coronal incision in all cases. In our experience, the transconjunctival-perilimbic approach to orbital exenteration proposed in this paper can be used successfully in skull base surgery. Combined with a coronal and transmandibular approach, it allows wide access to the facial skeleton/anterior skull base while avoiding skin incisions in the midface.

Invasive pulmonary and sino-orbital mucor mycosis in patient with SARS-Cov-2 infection with diabetic ketoacidosis

Patients with Severe acute respiratory syndrome coronavirus-2 (SARS-Cov-2) are susceptible for developing fungal infection due to uncontrolled diabetes or immunosuppression. A 46 years male presented with diabetic ketoacidosis, respiratory failure with peri orbital blackish discoloration with SARS-Cov-2 positive report. Computed tomography (CT) chest was suggestive of perihilar ground glass opacity and multiple thick-walled cavities. Left nasal cavity scrapings revealed hyaline aseptate hyphae and growth of Rhizopus arrhizus. Patient was initially managed conservatively with liposomal amphotericin B but later underwent orbital exenteration and finally succumbed. We want to emphasize higher mortality and aggressive management of mucor mycosis when it occurs with SARS-Cov-2 as a concurrent illness.

Ocular Surface Squamous Neoplasia With Coexistent Microbial Keratitis: Incidence, Risk Factors, Clinical Features, Microbiological Profile, and Treatment Outcome.

The purpose of this study was to evaluate the incidence, clinical features, microbiology, risk factors, and treatment outcomes in cases of ocular surface squamous neoplasia (OSSN) with coexisting microbial keratitis (MK). This was a retrospective case-control study from a cohort of 939 cases with OSSN. Twenty eyes (2%) with OSSN and MK were included in the study group and 100 age-matched eyes with only OSSN as controls. Most common presentation was a combination of pain, redness, watering, and decreased vision (50%) over a median duration of 14 days. Mean corneal surface involvement by MK was 48% with corneal perforation in 6 cases (30%). Microbiology showed 10 culture positive cases for Gram-positive organisms (n = 5), fungus (n = 4), or mixed infection (n = 1). In the salvaged eyes, MK resolved in 9 eyes (90%) on medical treatment at a mean duration of 30 days and keratoplasty was performed in 1 eye. OSSN treatment included wide excisional biopsy (n = 9/18; 50%), extended enucleation (n = 7/18; 39%), and orbital exenteration in 1. Over a mean follow-up of 12 months, vision salvage was achieved in 7 of 18 (39%) and globe salvage in 10 of 18 (55%). Logistic regression analysis showed the following significant risk factors for MK in OSSN: male sex, human immunodeficiency virus seropositivity, increasing tumor diameter, limbal epicenter, temporal quadrant, noduloulcerative morphology, pigmentation, scleral invasion, keratin, and corneal component of the OSSN lesion. Rarely, MK can coexist with OSSN leading to a poor treatment outcome. Male sex, human immunodeficiency virus seropositivity, large limbal pigmented OSSN lesion with keratin and corneal component, noduloulcerative morphology, and scleral invasion were risk factors for this association.

Simple, but effective: Nasal splinting for airway securement in free flap reconstruction following orbital exenteration.

Orbital exenteration is a disfiguring procedure that often results in free tissue transfer for reconstructive purposes. The reconstructive focus is the obliteration of dead space while sparing the nasal airway, particularly if the medial orbital wall was resected. Prolapse of transferred tissue into the nasal airway may cause breathing difficulties drastically compromising quality of life. The objective of this study was to demonstrate the effectiveness and feasibility of temporary nasal septum splints as mechanical support for transferred tissue, to prevent airway obstruction. This novel application technique was employed in three patients between 2017 and 2018. No flap loss or sino‐orbital fistulas were observed. On postoperative MRI and endoscopy, a patent nasal airway was observed at all times. Temporary nasal splinting in combination with free tissue transfer proved to be a simple, but effective reconstructive option for securing the nasal airway following orbital exenteration with resection of the medial orbital wall.

Indications for orbital exenteration in COVID-19 associated Rhino-orbito-cerebral Mucormycosis

Indications for orbital exenteration in COVID-19 associated Rhino-orbito-cerebral Mucormycosis - IJOOO- Print ISSN No: - 2581-5024 Online ISSN No:- 2581-5016 Article DOI No:- 10.18231/j.ijooo.2021.023, IP International Journal of Ocular Oncology and Oculoplasty-IP Int J Ocul Oncol Oculoplasty

Management outcomes of mucormycosis in COVID-19 patients: A preliminary report from a tertiary care hospital

BackgroundCoronavirus disease 2019 (COVID-19) continues to be a significant health problem worldwide. The unprecedented surge of mucormycosis in patients with COVID-19 is a new emerging challenge. Although a few studies documenting high incidence of mucormycosis in COVID -19 patients have recently emerged in literature, data pertaining to treatment outcomes in such cohorts is lacking. Here, we report our experience in management of mucormycosis in COVID-19 patients at our tertiary care centre. MethodThe clinical, imaging, histopathological and treatment data of 20 patients with mucormycosis (in setting of COVID-19) was analysed. Results35% and 65 % of cases developed mucormycosis in setting of active and recovered COVID-19 infections respectively. Diabetes mellitus was documented in 80% cases, with 55% demonstrating HbA1c >10%. Steroid was administered in 80% during COVID-19 illness. Imaging demonstrated paranasal sinus (PNS), orbital and intracranial extension in 100%, 55% and 20% patients respectively. All received amphotericin and underwent endoscopic debridement, 20% underwent orbital decompression and 5% maxillectomy with orbital exenteration. 6/20(30%) patients died (4 with rhino-orbito-cerebral disease, 1 with extensive orbito-maxillary involvement and 1 sino-nasal disease). All 6 patients received steroids and documented poor glycaemic control. ConclusionThe strong association of hyperglycemia and steroid intake with mucormycosis in COVID-19 cases warrants judicious use of corticosteroids and optimal glycaemic control. Our study highlights that good clinical outcome can be achieved in invasive mucormycosis provided prompt treatment is instituted with aggressive surgical debridement and antifungal medication.

Induction Chemotherapy for Orbit Preservation in Sinonasal Squamous Cell Carcinoma.

Sinonasal squamous cell carcinoma (SNSCC) is a rare and aggressive malignancy which often presents at an advanced stage. The gold-standard treatment includes negative-margin surgical resection plus adjuvant therapy. In cases of orbital invasion, surgery requires orbital exenteration which can carry significant morbidity and result in decreased quality of life. In selected patients, induction chemotherapy (IC) can allow for orbit preservation without compromising oncologic outcomes. The available literature will be briefly discussed.

Mucormycosis in patients with COVID-19: A cross-sectional descriptive multicentre study from Iran.

PurposeThe aim of the study was to report clinical features, contributing factors and outcome of patients with coronavirus disease 2019 (COVID‐19)‐associated mucormycosis (CAM).MethodsA cross‐sectional descriptive multicentre study was conducted on patients with biopsy‐proven mucormycosis with RT‐PCR‐confirmed COVID‐19 from April to September 2020. Demographics, the time interval between COVID‐19 and mucormycosis, underlying systemic diseases, clinical features, course of disease and outcomes were collected and analysed.ResultsFifteen patients with COVID‐19 and rhino‐orbital mucormycosis were observed. The median age of patients was 52 years (range 14–71), and 66% were male. The median interval time between COVID‐19 disease and diagnosis of mucormycosis was seven (range: 1–37) days. Among all, 13 patients (86%) had diabetes mellitus, while 7 (46.6%) previously received intravenous corticosteroid therapy. Five patients (33%) underwent orbital exenteration, while seven (47%) patients died from mucormycosis. Six patients (40%) received combined antifungal therapy and none that received combined antifungal therapy died.ConclusionClinicians should be aware that mucormycosis may be complication of COVID‐19 in high‐risk patients. Poor control of diabetes mellitus is an important predisposing factor for CAM. Systematic surveillance for control of diabetes mellitus and educating physician about the early diagnosis of CAM are suggested.

Periocular apocrine adenocarcinoma presenting as an orbital mass: clinicopathological features and management in four patients.

Apocrine adenocarcinoma is a cutaneous adnexal malignancy which can rarely arise from ocular structures. In this retrospective study, we report our experience with four patients who had primary periocular apocrine adenocarcinoma initially presenting with an orbital tumor. Data extracted included demographics, clinical, imaging, and histopathological features, and treatment outcomes. The definitive diagnosis was established after an incisional biopsy in all cases. Two patients were then managed with exenteration. The third patient underwent local resection followed by radiotherapy but had to be exenterated because of new tumor formation 7 years later. The fourth patient had to be managed with oral bicalutamide which kept the tumor stable for 3 years. Recurrence-free survival for the radical surgical treatment group was 10, 6, and 7 years respectively. Periocular apocrine adenocarcinoma may insidiously develop as an orbital mass without any clinically detectable primary eyelid skin or conjunctival lesions. This tumor must be in the differential diagnosis of medially located ill-defined orbital masses in patients over 50 years of age. Orbital exenteration appeared as an effective treatment of apocrine adenocarcinoma with orbital extension. Anti-androgenic treatment in an androgen receptor-positive tumor provided temporary local tumor control.

Epidemiology, clinical profile, management, and outcome of COVID-19-associated rhino-orbital-cerebral mucormycosis in 2826 patients in India - Collaborative OPAI-IJO Study on Mucormycosis in COVID-19 (COSMIC), Report 1.

Purpose:COVID-19-associated rhino-orbital-cerebral mucormycosis (ROCM) has reached epidemic proportion during India’s second wave of COVID-19 pandemic, with several risk factors being implicated in its pathogenesis. This study aimed to determine the patient demographics, risk factors including comorbidities, and medications used to treat COVID-19, presenting symptoms and signs, and the outcome of management.Methods:This was a retrospective, observational study of patients with COVID-19-associated ROCM managed or co-managed by ophthalmologists in India from January 1, 2020 to May 26, 2021.Results:Of the 2826 patients, the states of Gujarat (22%) and Maharashtra (21%) reported the highest number of ROCM. The mean age of patients was 51.9 years with a male preponderance (71%). While 57% of the patients needed oxygen support for COVID-19 infection, 87% of the patients were treated with corticosteroids, (21% for > 10 days). Diabetes mellitus (DM) was present in 78% of all patients. Most of the cases showed onset of symptoms of ROCM between day 10 and day 15 from the diagnosis of COVID-19, 56% developed within 14 days after COVID-19 diagnosis, while 44% had delayed onset beyond 14 days. Orbit was involved in 72% of patients, with stage 3c forming the bulk (27%). Overall treatment included intravenous amphotericin B in 73%, functional endoscopic sinus surgery (FESS)/paranasal sinus (PNS) debridement in 56%, orbital exenteration in 15%, and both FESS/PNS debridement and orbital exenteration in 17%. Intraorbital injection of amphotericin B was administered in 22%. At final follow-up, mortality was 14%. Disease stage >3b had poorer prognosis. Paranasal sinus debridement and orbital exenteration reduced the mortality rate from 52% to 39% in patients with stage 4 disease with intracranial extension (p < 0.05).Conclusion:Corticosteroids and DM are the most important predisposing factors in the development of COVID-19-associated ROCM. COVID-19 patients must be followed up beyond recovery. Awareness of red flag symptoms and signs, high index of clinical suspicion, prompt diagnosis, and early initiation of treatment with amphotericin B, aggressive surgical debridement of the PNS, and orbital exenteration, where indicated, are essential for successful outcome.