Transcutaneous retrobulbar injection of amphotericin B in rhino-orbital-cerebral mucormycosis: a review

ABSTRACT

Mucormycosis is an aggressive and potentially fatal invasive fungal infection. The most common form of mucormycosis is rhino-orbital-cerebral mucormycosis (ROCM). While it is commonly seen in immunocompromised patients, it is also known to affect healthy individuals. The global disease burden of ROCM has increased significantly following the surge in cases during the COVID-19 pandemic. Endoscopic sinus debridement, systemic antifungal therapy, and control of the underlying immunosuppressive condition are essential for the management of ROCM. Orbital involvement, however, presents a challenge to clinicians. Intervention strategies that have been described to treat orbital disease include orbital exenteration, conservative orbital debridement with or without irrigation with amphotericin B and transcutaneous retrobulbar injection of amphotericin B (TRAMB). Currently, there is a lack of clarity regarding the indications and outcomes of TRAMB as a treatment modality. In this review, the drug formulations used, the complications, and outcomes of previously described cases that have used TRAMB in cases of ROCM are discussed. Favorable outcomes following TRAMB depend on appropriate patient selection and radiological evidence of the orbital burden of the disease. This review aims to familiarize clinicians with objective parameters for patient selection for TRAMB, namely the extent of the disease, the clinical features, and radiological findings; viz. the clinical interpretation of areas of contrast uptake and those of necrosis. TRAMB can be considered as a viable option in select cases of orbital mucormycosis where exenteration or debridement are not indicated, or when there is limited orbital disease.

KEYWORDS:

• COVID-19
• exenteration
• fungal disease
• invasive sinus disease
• mucorales

Acknowledgments

The authors would like to acknowledge the inputs and support of Dr. Chhaya A. Shinde, Dr. Renuka A. Bradoo, Dr. Anagha Joshi, Dr. Kshitij Shah, Dr. Priyanka Rao, Dr. Lynn D’Cunha, Dr. Anupama Kokate, Dr. Akash Raghuwanshi, Dr. Disha Adole, Dr. Himalee Bhadange from the Department of Ophthalmology and Department of ENT, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

Akshay Gopinathan Nair serves as a consultant for HelpMeSee Inc., NY, USA and has received lecture fees from Carl Zeiss Meditec Inc.Tarjani Vivek Dave is supported by a research grant from Hyderabad Eye Research Foundation.