Transcutaneous retrobulbar amphotericin B for rhino-orbital-cerebral mucormycosis: a multi-center retrospective comparative study

ABSTRACT

Purpose

To assess whether transcutaneous retrobulbar amphotericin B injections (TRAMB) reduce exenteration rate without increasing mortality in rhino-orbital-cerebral mucormycosis (ROCM).

Methods

In this retrospective case–control study, 46 patients (51 eyes) with biopsy-proven ROCM were evaluated at 9 tertiary care institutions from 1998 to 2021. Patients were stratified by radiographic evidence of local orbital versus extensive involvement at presentation. Extensive involvement was defined by MRI or CT evidence of abnormal or loss of contrast enhancement of the orbital apex with or without cavernous sinus, bilateral orbital, or intracranial extension. Cases (+TRAMB) received TRAMB as adjunctive therapy while controls (−TRAMB) did not. Patient survival, globe survival, and vision/motility loss were compared between +TRAMB and -TRAMB groups. A generalized linear mixed effects model including demographic and clinical covariates was used to evaluate the impact of TRAMB on orbital exenteration and disease-specific mortality.

Results

Among eyes with local orbital involvement, exenteration was significantly lower in the +TRAMB group (1/8) versus -TRAMB (8/14) (p = 0.04). No significant difference in mortality was observed between the ±TRAMB groups. Among eyes with extensive involvement, there was no significant difference in exenteration or mortality rates between the ±TRAMB groups. Across all eyes, the number of TRAMB injections correlated with a statistically significant decreased rate of exenteration (p = 0.048); there was no correlation with mortality.

Conclusions

Patients with ROCM with local orbital involvement treated with adjunctive TRAMB demonstrated a lower exenteration rate and no increased risk of mortality. For extensive involvement, adjunctive TRAMB does not improve or worsen these outcomes.

KEYWORDS:

• Orbit
• mucormycosis
• retrobulbar
• amphotericin B
• injection

Acknowledgements

Evan Walker, MS UCSD Health research data analyst - statistical support; Sasan Moghimi, MD UCSD Shiley Eye Institute – statistical support, Sherya A. Shah, BA Stanford School of Medicine - data collection.

Disclosure statement

None of the following disclosures are relevant to the subject of this manuscript.

Andrea L. Kossler – consultant for Horizon Therapeutics and Immunovant.

Suzanne W. van Landingham – former consultant for Horizon Therapeutics.

Don O. Kikkawa – former consultant with Horizon Therapeutics, royalties from Elsevier, Ltd.

Bobby S. Korn – former consultant with Horizon Therapeutics, royalties from Elsevier, Ltd.

Catherine Y. Liu – site principal investigator for a Horizon Therapeutics-sponsored clinical trial, royalties from Wolter Kluwers Health.

Remaining authors – no disclosures.

Meeting presentation

This material in part was presented at the American Society of Ophthalmic Plastic and Reconstructive Surgery virtual fall scientific symposium in November 2020 as an oral presentation.

Additional information

Funding

This report was supported by an unrestricted grant from Research to Prevent Blindness (New York, NY).