Orbital Exenteration Research Articles

Adenocarcinoma NOS arising from accessory lacrimal glands: A case report and a review of the literature

Primary malignant epithelial tumours arising from accessory lacrimal glands (ALGs) are extremely rare, with only few cases reported in literature. They generally appear as gradually increasing masses of the upper or the lower eyelid. Only one case of primary adenocarcinoma or adenocarcinoma not otherwise specified (ACNOS) from ALGs has been reported in literature. Herein, we describe a case of ACNOS arising from ALGs with an atypical clinical presentation and review prior cases of ALGs epithelial malignancies reported in the literature. A 78-year-old man referred to our Ocular Oncology Unit for adjuvant therapy after the excision of a conjunctival tumour of the left eye with a histological diagnosis of squamous cell carcinoma. He underwent topical chemotherapy with MMC and during follow up he presented a multinodular iris mass in his left eye. The MRI of the orbit showed an ocular mass infiltrating orbital soft tissues of the inferior palpebral region with an involvement of the corresponding zygomatic cutis. We performed orbital exenteration and histological studies revealed an epithelial neoplasm with a solido-glandular growth pattern with lumens containing an eosinophilic material positive for PAS and PAS-D. The immunohistochemical findings confirmed the diagnosis of adenocarcinoma NOS from ALGs. Although ALGs epithelial malignancies are extremely uncommon, they should be considered in the differential diagnosis of ocular tumours. A vigilant approach towards these entities is required, since they can be clinically insidious and locally aggressive.

Managing mucormycosis in diabetic patients: A case report with critical review of the literature

Rhino-orbito-cerebral mucormycosis (ROCM) is a rare and potentially fatal invasive fungal infection which usually occurs in diabetic and other immunocompromised patients. This infection is associated with high morbidity and mortality rates. Prompt diagnosis and rapid aggressive surgical debridement and antimycotic therapy are essential for the patient's survival. Herein, we reviewed the localization and treatment strategies in patients with ROCM and diabetes as an underlying condition. Furthermore, we report one case of ROCM in our department. From 117 identified studies published in PubMed, 14 publications-containing data from 54 patients-were included. All patients were diagnosed clinically and by histopathological and/or bacteriological analysis for ROCM caused by the order Mucorales. Uncontrolled diabetes mellitus is one of the main risk factors for ROCM. A successful management of ROCM requires an early diagnosis, a prompt systemic antifungal therapy, and a rapid aggressive surgical debridement including exploration of the pterygopalatine fossa. An orbital exenteration may be necessary.

Custom made polymeric artificial eye: Appearance and characteristics of wear and care

A prosthetic eye may enhance the appearance of individuals who have lost sight due to injury or illness. Implanting a polymeric ocular prosthesis (POP) after an eye is surgically removed following an enucleation, evisceration, or orbital exenteration is always advised. This implant supports proper eyelid functioning as well as increasing patient confidence by restoring natural appearance. From February 2013 to January 2019, an experimental study was done on five hundred cases. The included patients experienced enucleation or evisceration procedure and had ocular prosthesis fitting. Data were entered, coded, cleaned, and analyzed using IBM SPSS statistics. A total of 500 cases completed the questionnaire. Of these, 55.8% were male, and 44.2% were female, with 50.2% of the patients lost their eyes because of injuries. In terms of operation variety, evisceration was done in 61.4% of the patients, enucleation in 37.6%, and others are in only five congenital cases (1%). According to this study, 28.8% of patients suffered from deposits formed on the prosthetic eye, while the absence of deposits was 71.2%. Significant psychological, as well as social consequences can result from the disfigurement associated with eye loss. Despite using the available materials and techniques to treat such patients, one needs to be a little creative and very inventive. Ocular prostheses act as a tool for restoring patients’ self-confidence and facilitating changes in their social convenience. Precise attention is essential to preserve the prosthesis and reminiscent of tissue health.

Lateral frontal galeal-cutaneous flap for reconstruction after orbital exenteration for advanced periorbital skin cancer.

Background/aimOrbital exenteration (OE) is one of the most disfiguring procedures leading to significant deformity. Defect reconstruction is challenging, especially in elderly patients. Herein, experiences with orbital exenteration and primary reconstruction with lateral frontal galeal-cutaneous flap based on superficial temporal artery were reviewed.Materials and methodsData on patients treated for nonmelanoma skin cancer invading the orbit during a 10-year period were analyzed. The patient demographics, tumor features, reconstructive techniques used, complications, and survival were recorded with a median follow-up of 27.5 months.ResultsIncluded in the study were 26 patients in whom OE was performed, comprising 14 males and 12 females, with a mean age of 75.29 years (range: 61–87). The majority of the patients were treated for basal cell carcinoma with medial cantus as the primary site. All of the defects were closed using a lateral frontal galeal-cutaneous flap based on the superficial temporal artery, and in 2 patients, a temporalis muscle pedicle flap was used as an additional flap for reconstruction of the orbital roof in order to separate the brain from the empty orbit, and it was then covered with the same galeal-cutaneous flap. In 19 patients, the frontal area was closed primarily, and in 7 patients, skin graft was used for the secondary defect. There was no flap loss. Tumor-related death was registered in 3 patients (inoperable recurrent tumors) (11.5%), 7 died from complications that were unrelated to the tumors (2 were operated for recurrent orbital tumors), and 16 survived.ConclusionThe preferred method for reconstruction after OE at our university affiliated center is lateral frontal galeal-cutaneous flap based on the superficial temporal artery. Flap harvesting is simple, safe, and obtains enough tissue to cover the defects, even after extended exenteration. The complication rate is low. The simultaneous use of this flap with pedicle temporalis muscle flap is suggested only for reconstruction of the scull base after anterior cranial fossa resection.

Reconstructive Outcomes of Multilayered Closure of Large Skull Base Dural Defects Following Open Anterior Craniofacial Resection.

Introduction Standardized reconstruction protocols for large open anterior skull base defects with dural resection are not well described. Here we report the outcomes and technique of a multilayered reconstructive algorithm utilizing local tissue, dural graft matrix, and microvascular free tissue transfer (MVFTT) for reconstruction of these deformities. Design This study is a retrospective review. Results Eleven patients (82% males) met inclusion criteria, with five (45%) having concurrent orbital exenteration and eight (73%) requiring maxillectomy. All patients required dural resection with or without intracranial tumor resection, with the average dural defect being 36.0 ± 25.9 cm 2 . Dural graft matrices and pericranial flaps were used for primary reconstruction of the dural defects, which were then reinforced with free fascia or muscle overlay by means of MVFTT. Eight (73%) patients underwent anterolateral thigh MVFTT, with the radial forearm, fibula, and vastus lateralis comprising the remainder. Average total surgical time of tumor resection and reconstruction was 14.9 ± 3.8 hours, with median length of hospitalization being 10 days (IQR: 9.5, 14). Continuous cerebrospinal fluid drainage through a lumber drain was utilized in 10 (91%) patients perioperatively, with an average length of indwelling drain of 5 days. Postoperative complications occurred in two (18%) patients who developed asymptomatic pneumocephalus that resolved with high-flow oxygen therapy. Conclusion A standardized multilayered closure technique of dural graft matrix, pericranial flap, and MVFTT overlay in the reconstruction of large open anterior craniofacial dural defects can assist the reconstructive team in approaching these complex deformities and may help prevent postoperative complications.

Orbital exenteration for conjunctival melanoma: comparison of long-term outcome between individualised and conventional techniques.

Growing evidence supports an individualised approach rather than radical surgery for conjunctival melanoma (CM). This study aimed to compare the long-term outcome between individualised and conventional exenteration techniques. Our study retrospectively recruited advanced CM (clinical T3 stage) patients treated with individualised (13 cases) or conventional (18 cases) exenteration from June 2014 to April 2019. The individualised approach preserved at least three quadrants of the orbit, and the conventional procedures removed at least one third of the orbital tissues. The medical records were collected and analyzed during April 2020, including demographics, tumour characteristics, surgical details, postoperative rehabilitation and tumour-related prognosis. The tumour basal diameter was statistically (P = 0.011) larger in the conventional group (23.3 ± 7.6 mm) than in the individualised group (15.4 ± 6.3 mm). More tissues were preserved in the individualised group, resulting in a shorter duration of wound healing (2.1 ± 0.6 vs. 3.6 ± 2.0 weeks, P = 0.018) and less incidence of hollow appearance (15% vs. 72%, P = 0.003) than the conventional group. After follow-up for 39.3 ± 17.3 months, a comparison of survival curves showed no significant differences (P = 0.638) between the two groups. The 1- and 2-year overall survival rates were estimated as 100% and 80.0% in the individualised group, and 93.8% and 72.5% in the conventional group, respectively. Low or mixed pigmentation was identified as the risk factor for tumour-related mortality based on multivariate regression analysis. The individualised approach to exenteration offers improved aesthetic results while still maximises the curable chance for advanced CM.

Rehabilitation of a defect secondary to sino-orbital mucormycosis- A prosthodontic challenge

Mucormycosis is a rapidly progressing and invasive form of fungal infection involving the nose and paranasal sinuses of head and neck region with high mortality and morbidity. Compromised immunological conditions like uncontrolled diabetics mellitus, Leukaemia, prolonged use of steroids are the most common predisposing factors for this disease. Aggressive surgical debridement including resection of involved maxillofacial structures like orbit, maxilla and/or nose is the commonly used treatment protocol in such conditions. Rehabilitation of such large maxillofacial defects is a Prosthodontic challenge and many problems are encountered in rehabilitation like lack of retention due to dislodging forces exerted by scarred post surgical soft tissues, lack of bony base, lost structures of the posterior palatal seal area, multiple defect sites and compromised medical status due to comorbidities that also affects healing rate of the defect. This clinical report describes prosthetic rehabilitation of a patient with residual maxillary and orbital defects secondary to surgical management of sinoorbital mucormycosis with a combination prosthesis comprising of orbital and obturator using an innovative method of achieving retention between the two, thereby providing complete functional and esthetic rehabilitation of the patient. Keywords: Sinoorbital Mucormycosis, Maxillectomy, Orbital Exenteration, Retention, Obturator, Orbital Prosthesis.

Conjunctival and uveal melanoma: Survival and risk factors following orbital exenteration.

This study aims to analyse disease-free survival, overall survival and risk factors after orbital exenteration in patients with conjunctival and uveal melanoma. Patients who underwent orbital exenteration due to conjunctival and uveal melanoma were included in this retrospective study (March 2000 to March 2018). A total of 76 patients were enrolled in this study: 60 patients had a conjunctival melanoma and 16 had a uveal melanoma. In conjunctival melanoma, the mean age was 68.4 years. The overall survival rate was 82% after 1 year and 52% after 5 years. Univariate analysis of overall survival found that the following parameters were predictive of a worse prognosis: gender, extent of the primary tumour, lymph node metastases, distant metastases, adjuvant chemotherapy or radiotherapy and relapse. In multivariate analysis, relapse and adjuvant radiotherapy appeared to contribute to a significantly worse prognosis. In uveal melanoma, the mean age was 63.6 years. Eleven patients died during follow-up (mean follow up 30.7 months). The overall survival and disease-free survival rates after 1 year were 62% and 57%, respectively. An analysis of risk factors was not possible due to the small number of cases. Orbital exenterations in conjunctival and uveal melanoma are rarely necessary, but can be performed as an ultima ratio treatment with curative intent. Disease-free survival and overall survival are significantly lower for both groups due to the advanced stage of the disease compared to patients treated without exenteration in the literature. If a recurrence occurs after exenteration, the prognosis is poor in both groups.

Secondary orbital exenteration for conjunctival melanoma: A study of 25 cases

The treatment of conjunctival melanoma is most often conservative, but exenteration is sometimes necessary in order to achieve local control of the disease. It can be performed as a primary procedure in cases of locally advanced disease or as a secondary procedure after one or more recurrences. No benefit to secondary exenteration on patient survival has been demonstrated to date for conjunctival melanoma, and it is generally considered a palliative procedure. Single-center retrospective study performed in the ocular oncology department of the Institut Curie (Paris, France). We included all patients who underwent secondary orbital exenteration for conjunctival melanoma between January 2008 and January 2016. Twenty-five patients underwent secondary exenteration for conjunctival melanoma. The maximum number of local recurrences prior to exenteration was six. Metastases occurred in 11 patients after exenteration and were more common when there was a greater tumor thickness on histology, if the tumor had not been treated initially in an ocular oncology center, or if there had been a greater number of local recurrences before the secondary exenteration was performed. Seventy-five percent of patients developed metastases when the exenteration was performed after 5 or 6 local recurrences. This study suggests that early secondary exenteration (i.e. after a number of local recurrences less than or equal to 4) may reduce the occurrence of metastases (and therefore improve patient survival) in conjunctival melanoma. Thus, secondary exenteration might be a curative surgery in some patients with recurrent disease.

EGFR Mutated Lung Adenocarcinoma with Secondary Glaucoma as Early Manifestation: A Case Report

Background: Orbital metastases are rare in pulmonary adenocarcinoma and can be manifested as glaucoma.Case: A 64-year-old male patient complained of swelling, redness, painful and protruded left eye. Physical and radiological examination revealed mass in the right lung, retrobulbar intraconal mass of the left oculi, and metastases in the ribs, liver, brain, and vertebrae. Result of bronchial mucosal biopsy showed adenocarcinoma. Epidermal growth factor receptor (EGFR) mutation examinations detected exon 19 deletions, therefore Gefitinib was given. Left orbital exenteration was performed and obtained a biopsy result of adenocarcinoma metastases.Conclusion: Orbital metastasis occurs by hematogenous pathway due to direct access of systemic circulation to left orbital blood flow. Glaucoma as a symptom of orbital metastases can appear before primary tumor symptoms, because lung cancer often does not show specific symptoms until advanced stage. Definitive treatment consists of targeted therapy and surgical management for metastases.

Mucor in a Viral Land: A Tale of Two Pathogens.

Purpose:COVID-19 infection, its treatment, resultant immunosuppression, and pre-existing comorbidities have made patients vulnerable to secondary infections including mucormycosis. It is important to understand the presentation, temporal sequence, risk factors, and outcomes to undertake measures for prevention and treatment.Methods:We conducted a retrospective, interventional study on six consecutive patients with COVID-19 who developed rhino-orbital mucormycosis and were managed at two tertiary ophthalmic referral centers in India between August 1 and December 15, 2020. Diagnosis of mucormycosis was based on clinical features, culture, and histopathology from sinus biopsy. Patients were treated with intravenous liposomal amphotericin B with addition of posaconazole and surgical debridement of necrotic tissue.Results:All patients were male, mean age 60.5 ± 12 (46.2–73.9) years, type 2 diabetics with mean blood glucose level of 222.5 ± 144.4 (86–404) mg/dL. Except for one patient who was diagnosed with mucormycosis concurrently with COVID-19, all patients received systemic corticosteroids for the treatment of COVID-19. The mean duration between diagnosis of COVID-19 and development of symptoms of mucor was 15.6 ± 9.6 (3–42) days. All patients underwent endoscopic sinus debridement, whereas two patients required orbital exenteration. At the last follow-up, all six patients were alive, on antifungal therapy.Conclusion:Mucormycosis is a life-threatening, opportunistic infection, and patients with moderate to severe COVID-19 are more susceptible to it. Uncontrolled diabetes mellitus and use of corticosteroids increase the risk of invasive fungal infection with mucormycosis which can develop during the course of the illness or as a sequelae. High index of suspicion, early diagnosis, and appropriate management can improve survival.

Reconstruction of Orbital Exenteration Defects with Cheek Rotation Flaps: Indications, Technique, Complications, Rehabilitation, and Survival.

The objective of this study was to examine the role of cheek rotation flaps in the reconstruction of orbital defects after exenteration. From January 2000 to August 2018, patients undergoing orbital exenteration and reconstruction with cheek rotation flaps were enrolled in this retrospective study. All patients were evaluated for wound complications, orbital rehabilitation, tumor relapse, and survival. Thirty patients completed the study. Fourteen complications allocated to 11 patients were assessed. The most common complications were seroma (13%), temporary facial nerve weakness (13%), and partial necrosis of the flap (10%). A major complication occurred in a total of two patients (7%), so that surgical correction was necessary. Eleven patients had a relapse; 15 patients died as part of the follow-up. Fifteen patients were treated with facial prostheses. The overall survival rate was 61% after 1 year and 42% after 5 years. Follow-up periods ranged from 6 to 95 months. Cheek rotation flap reconstruction after exenteration is a reliable method with a low rate of major complications. It is indicated when an approach to the parotid gland or the neck region is necessary because of suspected lymph node metastasis and in elderly patients because of their skin's laxity. It can be performed as primary or secondary reconstruction. Good esthetic results can be achieved, especially after endosseous implantation.

A rare case of maxillary sinus cancer that involve the orbit and adjacent structures

43year old male diagnosed as case of Maxillary sinus cancer that involved the orbit. CT scan of face revealed large ill defined extensively infiltrated soft tissue mass of 7*5*4.4 cm in maxillary sinus which extended to infratemporal fossa and erosion of floor of the right orbit with infiltration of right inferior rectus muscle. The prognosis of maxillary sinus cancer with involvement adjacent structures is not very good (usually diagnosed at an advanced stage), so to attain an improved result it was essential to secure adequate resection of margins. So we followed a standard treatment protocol that was total maxillectomy with orbital exenteration, followed by postoperative radiation therapy.

Total orbital exenteration - Experience from a tertiary cancer care center in Northern India

Introduction: Orbital exenteration (OE) is a defacing procedure reserved for advanced head and neck malignancies involving the orbit. Even though it is cosmetically unappealing and associated with complete loss of vision in one eye, the procedure has low surgical morbidity and recurrence rates and should be considered in appropriate patients after adequate patient counseling. Due to relative rarity of the procedure, there is a paucity of literature, particularly in India. Aim: To analyze the role and indications of OE, operative details, morbidity, and postoperative complications in patients who had undergone total OE in a tertiary care cancer hospital. Materials and Methods: We retrospectively reviewed 5-year (2011–2016) data of those who had OE from our computerized database. The retrieved data were analyzed for demographic profile, operative details, morbidity, and survival rates. Results: Out of 20 patients analyzed, 13 were male and 7 were female. Majority of the patients have secondary eyeball extension (15/20). Most frequent indication for exenteration was tumor of eyelid origin. Reconstruction after surgery was done by temporalis flap (n = 10), anterolateral thigh-free flap (n = 6), and split skin graft (n = 4). None of the patients had any intraoperative complications. One patient developed flap necrosis and managed by flap revision. One patient had wound dehiscence and managed conservatively. At a mean follow-up of 20 ± 9.6 months, two patients had recurrence of primary disease. Mortality occurred in two patients; 1 case for disease related and another one for other medical condition. Conclusion: The OE has still a role and is indicated for a variety of conditions. The surgical procedure remains safe, and major morbidity is dictated by the type of reconstruction. Although skin graft is the simplest reconstructive option, many a times, myocutaneous/free flap is required in advanced cases.

Incidence, cumulative mortality and factors affecting the outcome of COVID-19-associated mucormycosis from Western India.

Purpose:To report the incidence, cumulative mortality, and factors influencing the outcomes from a large series of COVID-19-associated mucormycosis (CAM) from western India.Methods:Consecutive patients with CAM between March 1 and May 10, 2021, with a minimum follow-up of 1 month were included. We recorded the presence of diabetes, use of steroids, and need for non-invasive ventilation (NIV) from the case files. The features of orbital involvement, treatment administered, and outcomes, i.e., death, orbital exenteration, or recovery were noted. Cumulative probability of adverse outcomes, defined as either death or exenteration, was reported using survival analysis.Results:We treated 67 cases of CAM and found an incidence of 13.6 cases per 1,000 patients post-moderate to severe COVID-19. Uncontrolled diabetes (90%) with ketoacidosis (40%) and prior systemic steroids (84%) were the strongest predispositions. The onset of CAM was 15.1 ± 9.5 days (range: 6–42 days) after recovery from COVID-19. The cumulative probability of an adverse outcome was 38% (95% confidence intervals [CI] = 23.7–56.9%) on day 20. The patients who required NIV during COVID-19 were at seven times higher risk of experiencing an adverse outcome (hazard ratios [HR] = 6.92, 95% CI = 2.9–16.2) while those who received amphotericin– -B had a 61% lower risk (HR = 0.39, 95% CI = 0.16–0.97).Conclusion:The current outbreak of CAM was seen predominantly in uncontrolled diabetics, especially with ketoacidosis and steroid intake. The cumulative probability of death or orbital exenteration was 38% at day 20 of the infection and those who required NIV and did not receive amphotericin-B were at a high risk of these outcomes.

Locally Advanced Carcinoma of Maxillary Sinus with Orbital Involvement

Maxillary sinus carcinoma is a rare neoplasm, with incidence of 0.2 to 0.8% of all systemic malignancies. Patients are diagnosed in the advanced stage when there is orbital invasion with abnormal ocular signs and symptoms. The standard treatment of maxillary sinus carcinoma is en bloc radical maxillectomy along with orbital exenteration, followed by postoperative adjuvant therapy. Orbital exenteration is used when the malignancy extends to the orbit in case of squamous/basal cell carcinoma. The aim of the current review is to provide an insight into the management of advanced maxillary carcinoma with orbital involvement in a 42-year-old male.

Correlates of depression, anxiety, self-esteem, and suicidal ideas in COVID-associated mucormycosis patients and the effects of treatment.

Aim:The aim was to study the correlates of depression, anxiety, self-esteem, and suicidal ideas in patients of COVID-associated mucormycosis (CAM) and effects of treatment.Materials and Methods:A cross-sectional, analytical study was performed in a tertiary care center in Western Maharashtra. By purposive sampling, 34 patients of CAM were included in the study with their informed consent and after obtaining ethical clearance. A self-made questionnaire to include demographic and clinical details was filled. Hospital Anxiety and Depression Scale (HADS), Rosenberg Self-Esteem Scale (RSES), and Suicidal Ideation Attributes Scale (SIDAS) were applied after initial diagnosis. The HADS, RSES, and SIDAS were reapplied after their operative treatment.Results:A significant reduction in anxiety and depression scores postoperatively was seen. No significant difference was found in self-esteem or suicidal ideas postoperatively in the study population. However, patients who underwent orbital exenteration showed a significant reduction in level of self-esteem with anxiety and depression postoperatively. No specific correlation was found between the computed tomography score, family history, intensive care unit admission, or orbital exenteration with anxiety, depression, self-esteem, and suicidal ideas.Conclusion:Levels of anxiety and depression in patients of CAM reduced significantly after treatment, but self-esteem worsened in males more than females owing to disfigurement. There is a need of psychological counseling in patients of mucormycosis undergoing a debilitating surgery both pre- and postoperatively for a better outcome and recovery.

A case of invasive fungal sinusitis treated with orbital exenteration

A case of invasive fungal sinusitis treated with orbital exenteration

Post COVID-19 mucormycosis: A case series

Objective: To evaluate the associated factors between COVID-19 and mucormycosis.Methods: Twenty-two patients of COVID-19 associated mucormycosis (including 3 asymptomatic patients who were cured of COVID-19) from a single medical unit of our institute were included. A detailed history was noted, with special emphasis on the time of onset of mucormycosis symptoms, presence of comorbidities, including new onset diabetes, severity of COVID-19, oxygen requirement, details of receipt of steroids and immunomodulators such as tocilizumab, imaging findings, including the number of sinuses involved, bony erosions, orbital and cerebral involvement, microscopy, culture and histopathology reports and antifungals given. Surgical interventions including number of debridements, orbital exenteration, maxillectomy, and the vaccination status were noted.Results: All 22 patients had rhino-orbital cerebral mucormycosis, 27.27% in the first wave and 72.73% during the second wave. Diabetes was the commonest comorbidity, and 40.91% patients were newly detected diabetics. The time of presentation in relation to their COVID-19 symptoms was 8-15 days (average 12.5 days). Ten out of 22 (45.45%) had asymptomatic or mild COVID-19 and 40.91% did not require supplemental oxygen. Five out of 22 (22.73%) did not receive steroids. Twelve out of 22 (54.55%) had orbital involvement, 3 (13.64%) had palatal ulcer and 4 (18.18%) had cerebral involvement and all these had progressed in spite of treatment with appropriate antifungals.Conclusions: COVID-19 associated mucormycosis is a frequent, lethal, post COVID-19 complication, occurring even in mild and asymptomatic cases who have not received steroids or oxygen.

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

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.