Orbit-sparing local amphotericin B and retrobulbar liposomal bupivacaine as an alternative to exenteration for amphotericin-resistant invasive Aspergillus orbital disease

Purpose: To report an orbit-sparing alternative to exenteration for amphotericin-resistant invasive fungal orbital disease with a painful blind eye.

Methods: Case report. A 72-year-old man with insulin-dependent diabetes had left invasive Aspergillus fumigatus sinusitis that progressed despite five debridements, causing no light perception, cavernous sinus syndrome with ductions limited in all gazes, and severe pain in the blind eye. The isolate was amphotericin-nonsusceptible (minimum inhibitory concentration [MIC] 2 µg/mL) and posaconazole-susceptible. Systemic amphotericin B caused acute kidney injury, and exenteration was recommended. Because posaconazole is available only orally, local therapy used amphotericin B at concentrations far exceeding the MIC. Combined otolaryngology–ophthalmology surgery included endoscopic debridement, optic nerve decompression, and intralesional amphotericin B; retrobulbar liposomal bupivacaine 1.3% (4 mL); intravitreal amphotericin B (2.5 µg/0.05 mL); and exploration of all four rectus muscles with periorbital debridement and high-concentration sub-Tenon amphotericin B around each muscle. Oral posaconazole was continued.

Results: Pain resolved and remained 0/10 through 6 months without further intervention. Ductions returned to full by 6 weeks. Magnetic resonance imaging at 11 weeks showed stable disease, and at 6 months multidisciplinary review found the fungal lesion decreased in size. The globe and orbit were preserved, and the fellow eye achieved 20/20 visual acuity.

Conclusions: Debridement with high-concentration local amphotericin B can overcome in vitro resistance without added nephrotoxicity, while oral posaconazole provides systemic control. Retrobulbar liposomal bupivacaine gave durable relief of blind-eye pain. This approach may spare medically fragile patients from exenteration.

Keywords: Invasive Fungal Sinusitis, Aspergillus Fumigatus, Amphotericin B Resistance, Orbital Exenteration, Liposomal Bupivacaine

Suzie T. Nemmers, MD, is a civilian ophthalmologist at Tripler Army Medical Center in Honolulu, Hawaii, where she has practiced since 2010, specializing in adult and pediatric ophthalmology, strabismus, and refractive surgery. Her military medical service dates to 2001, and her clinical and surgical work spans complex orbital, strabismus, and refractive cases in a multidisciplinary military medical setting.