A study on the ocular outcomes of transcutaneous retrobulbar administration of injection liposomal amphotericin-b in rhino-orbito- cerebral mucormycosis

Abstract

Background: Rhino-orbito-cerebral Mucormycosis (ROCM) is an angio invasive fungal disease affecting the immunocompromised and patients with other debilitating diseases. There has been an exponential rise in its incidence post the second wave of COVID 19 in India, as the COVID infection itself acts as a risk factor along with others like uncontrolled Diabetes, over use of Zinc supplements, Oxygen therapy, usage of steroids. The fungus enters the Paranasal sinuses and from there spreads rapidly to Orbits, Maxilla, Orbital apex and Intracranial extension. Materials and Methods: 100 cases of Post COVID Rhino-orbito-cerebral Mucormycosis attending the Government General Hospital, Guntur were taken in this study, during the period of May 2021 to July 20th 2021. Appropriate history, clinical examination and all the required investigations were performed by a multi-speciality team of doctors. All the cases with proven fungal elements on biopsy or proven fungal invasion of Orbits/ Orbital apex/ Extraocular muscles/ Retrobulbar fat were administered Transcutaneous Retrobulbar Injection Liposomal Amphotericin-B(TRAMB) 3.5 mg/ml given for 4 doses and followed for a period of 1 week and depending on the clinical improvement, the doses are repeated. 100 cases were followed closely and the ocular findings were recorded and results are tabulated. Results: 100 cases of proven fungal etiology are followed after administering TRAMB for a minimum of 1 month. Of the 100 patients included in the study, 63 patients showed improvement in the ocular symptoms either resolution of Proptosis, ptosis, improvement in Visual acuity. 18 patients had neither improvement nor deterioration in ocular symptoms. 19 patients had deterioration in their ocular status despite the injections and thus are considered for either Exenteration/ Enucleation/ Evisceration depending on the orbital extension. 1 Exenteration, 9 Enucleations, 3 Evisceration are performed. Lateral Canthotomy and Cantholysis with Orbital lavage with Liposomal Amphotericin-B is done for 10 patients. Conclusion: Of the 100 cases given TRAMB, 63% of cases showed improvement in their symptoms. 18% cases had neither improvement nor deterioration. 19% of cases had deterioration in their ocular condition. Early diagnosis and intervention has resulted in better prognosis and improvement in ocular complaints. In patients with delay in the diagnosis or intervention led to intracranial spread and resulted in loss of vision for whom destructive ocular surgeries are performed to contain the further spread.