Title : Ocular Manifestations and Management of Rhino-orbital Mucormycosis during the time of COVID-19
Abstract:
Background: Mucormycosis is a deadly opportunistic fungal infection characterized by direct invasion with marked tissue necrosis of adjacent structures followed by rapid progression and angioinvasion from the nasal and sinus mucosa into the orbit and brain. It has been an increase in the incidence of rhino-orbital mucormycosis worldwide during the time of COVID-19. Prolonged hospital stay with the possibility of nosocomial infection, immunosuppression treatments, and associated comorbidities like diabetes mellitus are risk factors attributed to the increasing incidence of rhino-orbital mucormycosis.
Purpose: This study aimed to present the patient demographics, risk factors including comorbidities, and severity and treatment of COVID-19 focused on ocular symptoms and signs, and management's outcome.
Methods: This retrospective observational study included 30 eyes of 29 COVID-19 patients hospitalized between January 2021 and January 2022, and developed microbiologically confirmed ROM co-infection.
Results: There were 23 and 6 women with a mean age of 66.4 ± 11.5 years. Twenty-two patients had uncontrolled type 2 diabetes with a mean diagnosis duration of 12.2 ± 4.1 years. All patients had COVID-19-associated acute respiratory distress syndrome and received corticosteroids and/or tocilizumab. The mean time interval between COVID-19 diagnosis and rhino-orbital mucormycosis diagnosis was 16.8 ± 6.4 days. Eighteen patients (62.1%) had orbital apex syndrome, and 12 patients (37.9%) were examined with orbital cellulitis. Endophthalmitis was detected in 46.7% of eyes, and one of these eyes developed retinoschisis. Posterior scleritis was detected based on ocular ultrasonographic findings in 5 (16.7%) eyes. One patient (3.4%) developed mucor keratitis, and the other (3.4%) was examined with periocular cutaneous mucormycosis. CT scan and/or MRI revealed sino-orbital involvement in all patients, and seven of these had cerebral involvement at initial presentation. All patients underwent radical debridement of the involved sinuses and received intravenous and retrobulbar liposomal amphotericin B. Intravitreal, posterior sub-tenon, and topical liposomal amphotericin B were performed in patients with endophthalmitis, patients with posterior scleritis, and patients with keratitis, respectively. Despite all measures, 68.9% of the patients died.
Conclusions: Therapeutic management in rhino-orbital mucormycosis includes extensive surgical debridement, local and systemic antifungal therapy, regulation of the underlying metabolic and/or impaired immunological status, and control of other concomitant infections. The early recognition of ocular symptoms and signs and a multidisciplinary treatment strategy are crucial to help salvage the life and eyes of these patients.
