Localized surgical debridement for the management of orbital mucormycosis

Purpose: To describe the role of localized debridement and instillation of amphotericin B for the management of orbital mucormycosis post COVID?19 infection with a view to avoid exenteration. Methods: The records of all patients with orbital mucormycosis post COVID?19 infection in the last 6 months from December 2020 to June 2021 were evaluated, and ten patients were identified who were successfully managed with localized debridement, that is, removing the fungal tissue and necrotic material and amphotericin B gel instillation locally. MRI scan was used to identify the area of fungal infiltration and presence of necrotic material. Early surgery in the form of transconjunctival orbitotomy was performed for disease in the infraorbital fissure area, and superior transcutaneous lid crease approach was employed for disease in the superomedial orbit or medial orbit. Most patients had lid edema, ptosis, and proptosis; this resolved with the medication. Systemic antifungals were given and the follow?up ranged from 1 to 5 months. Results: The ptosis, proptosis, and lid edema subsided in all, except in one patient who had residual ptosis and in one who had residual ophthalmoplegia. Vision deficit did not occur in any patient. All patients were successfully discharged on oral antifungal medication. Conclusion: Localized clearance of the fungal tissue and the necrotic material is a good option to avoid exenteration in cases of orbital mucormycosis, avoiding disfigurement and mental trauma to the patient

Retrobulbar injection of amphotericin B using intravenous cannula for post-COVID-19 rhino-orbital mucormycosis

Rhino-orbital mucormycosis has seen a huge resurgence in patients post COVID-19 infection. In patients with minimal orbital disease and especially with preserved vision, retrobulbar injections of amphotericin B can be of great help in controlling the disease. Instead of giving daily injections of amphotericin B using needles every time, we used an 18-gauge intravenous (IV) cannula with injection port and suture holes to deliver the amphotericin into the orbital space for a period of 5 days. Patients were more compliant and less distressed with this method compared with being given an injection with a needle daily. We got a good response in terms of orbital disease regression with this method. In our review of the literature, we did not come across any such case of amphotericin B injection using an IV cannula. Injection of amphotericin B into the orbit using an IV cannula is a viable and easy treatment option for cases of rhino-orbital mucormycosis

Electron beam radiotherapy for the management of recurrent extensive ocular surface squamous neoplasia with orbital extension.

Recurrent extensive ocular surface squamous neoplasia (OSSN) with orbital invasion can be successfully managed with external radiotherapy using electrons resulting in eye and vision salvage. We report a case of right eye recurrent OSSN in an immunocompetent adult Indian male, with extensive orbital involvement. The patient had two previous surgical excisions with recurrent disease. At this stage, conventionally exenteration is considered the treatment modality. However, he was treated with 5040 cGy radiotherapy (15eV electrons) resulting in complete disease regression. At the end of 3 years follow‑up, the patient was disease free, maintained a vision of 20/25, with mild dry eye, well‑managed with topical lubricants. Extensive OSSN with orbital invasion does not always need exenteration. External beam electron radiotherapy provides a noninvasive cure with organ and vision salvage and should be considered in extensive OSSN not amenable to simple excision biopsies. Long‑term studies to evaluate the effect of radiation on such eyes are suggested.

Novel surgical technique for the management of partial cryptophthalmos.

We report a case of a 2‑month‑old baby with bilateral nonsyndromic partial cryptophthalmos presenting with upper eyelid incomplete development and fusion to the cornea with resultant inability to close the eyes. He was managed successfully with bilateral upper lid reconstruction with composite graft using maternal skin and oral mucous membrane, amniotic membrane, and donor scleral graft. After this one stage surgery, lids were well‑formed, and the patient was able to close both eyes, thus achieving good anatomical, functional, and cosmetic outcome.

Bilateral multiple extraocular muscle metastasis from breast carcinoma.

We report a rare presentation of an initially misdiagnosed case of a pseudotumor, which on histopathology was diagnosed as bilateral breast metastases of lobular carcinoma involving multiple extraocular muscles. A 61-year-old lady presented with external ophthalmoplegia and diplopia. Incisional biopsy was performed using a lid crease approach and the patient received radiotherapy and hormonal therapy. Following prolonged hormonal therapy, complete remission was achieved, with improvement in ocular motility and resolution of diplopia, about 18 months after the initial presentation. Multiple extraocular muscle involvement by breast carcinoma metastasis is very rare and should be considered in the differential diagnosis, especially in patients with a prior history of breast carcinoma.

Botulinum toxin in the management of acquired motor fusion deficiency.

Acquired disruption of motor fusion is a rare condition characterized by intractable diplopia. Management of these patients is extremely difficult. Prisms in any combination or even surgery may not help relieve their symptoms. We describe a longstanding case of acquired motor fusion disruption which was managed successfully with botulinum toxin injection.

Lateral fixation of sclera to the periosteum with medial rectus disinsertion for severe myopic strabismus fixus.

Myopic strabismus fixus is characterized by severe ocular motility restriction with the development of progressive esotropia and hypotropia. Management of severe cases with strongly positive forced duction test can be challenging. We describe a longstanding case of myopic strabismus fixus, which was managed by bilateral medial rectus disinsertion and scleral fixation laterally to the periosteum.

Amniotic membrane transplantation: a review of current indications in the management of ophthalmic disorders.

Amniotic membrane transplantation is currently being used for a continuously widening spectrum of ophthalmic indications. It has gained widespread attention as an effective method of reconstruction of the ocular surface. Amniotic membrane has a unique combination of properties, including the facilitation of migration of epithelial cells, the reinforcement of basal cellular adhesion and the encouragement of epithelial differentiation. Its ability to modulate stromal scarring and its anti-inflammatory activity has led to its use in the treatment of ocular surface pathology as well as an adjunct to limbal stem cell grafts. Amniotic membrane transplantation has been used for reconstruction of the corneal surface in the setting of persistent epithelial defects, partial limbal stem cell deficiency, bullous keratopathy and corneoscleral ulcers. It has also been used in conjunction with limbal stem cell transplantation for total limbal stem cell deficiency. Amniotic membrane grafts have been effectively used as a conjunctival substitute for reconstruction of conjunctival defects following removal of pterygia, conjunctival lesions and symblephara. More recently, amniotic membrane has been used as a substrate for ex vivo cultivation of limbal, corneal and conjunctival epithelial cells. This article reviews the current literature on the applications of amniotic membrane transplantation and its outcome in various ophthalmic conditions.

Isolated giant xanthogranuloma of the orbit.

Xanthogranuloma is an uncommon tumor in the orbit and is usually associated with systemic diseases or blood abnormalities. We report an extremely rare presentation of isolated orbital xanthogranuloma unassociated with any systemic disease, hematological or biochemical abnormalities. A 47-year-old physician presented with proptosis of the left eye of three years duration with yellowish skin plaques. The CT scan revealed a well-defined heterogeneous mass in the medial orbit. There was no evidence of systemic, serum or biochemical abnormalities. The mass was removed by a medial orbitotomy. Histopathology confirmed the diagnosis based on the presence of inflammatory infiltrates, histiocytes and Touton giant cells.