Voriconazole in the treatment of invasive aspergillosis of orbit.

Background: The aim of the study was to evaluate the outcomes of voriconazole in terms of functional recovery and response on imaging in the management of invasive aspergillosis of orbit. Methods: This was a prospective non-comparative interventional study. Diagnosed cases of invasive orbital aspergillosis were studied in a tertiary care hospital. Intravenous voriconazole followed by oral treatment was given. Sinus debridement was done, where needed. The response to treatment was assessed clinically and on radiology. Results: A total of 10 diagnosed cases of invasive orbital aspergillosis were studied. Nine cases (90%) occurred in immunocompetent patients. Predisposing sinus infection was seen in 8 patients (80%). The most common presenting complaint was the protrusion of eye. On voriconazole treatment, there was a statistically significant improvement in vision and extraocular movements from first week onwards (p = 0.01 and p = 0.02, respectively) and reduction in proptosis from second week onwards (p = 0.003). Imaging was done at three months follow-up which revealed a good response to treatment in 90% of patients. All patients tolerated the drug well except one who had transient hepatic dysfunction. The mean follow-up was 5.8 months (range: 3-12 months). There was no recurrence of disease till the last follow-up. Conclusion: Invasive orbital aspergillosis commonly presents as sino-orbital disease, mostly in immunocompetent adult patients. Voriconazole is a safe and effective drug with good short-term clinical outcome.

Trends in orbital cellulitis severity and management: 2016 through 2022.

PURPOSE: To characterize trends in orbital cellulitis (OC) severity and management from 2016 through 2022, including assessment of effects from the COVID-19 pandemic. METHODS: A retrospective chart review was conducted at a tertiary care center using an electronic medical record search of OC from January 1 2016 to January 1 2023. Radiography was used to categorize patients into three cohorts - OC without abscess, OC with subperiosteal abscess (SPA), and OC with orbital abscess (OA). Infection cohort and age group [pediatric (<9 years old), adolescent (9-18 years), adult (>18 years)] were compared across years. Subgroup analysis was performed in the SPA cohort. Comparisons were made between the time periods prior to and after the start of the COVID-19 pandemic. RESULTS: From 2016-2022, there were 247 (67.3%) cases of OC, 103 (28.1%) SPA, and 17 (4.6%) OA. The year 2022 incurred higher rates of SPA and OA (p = 0.035), pediatric infections (p = 0.008), and co-morbid sinusitis (p = 0.005) compared to all preceding years. Rates were similar from 2016 through 2021. Within the SPA cohort, rates of surgical intervention and outcomes were similar across all years. Rate of abscess formation was significantly higher during the COVID-19 pandemic compared to the pre-pandemic era (p = 0.033). CONCLUSION: The severity of OC leading up to the COVID-19 pandemic appeared steady. After pandemic onset, a delayed increase in abscess formation, predominantly affecting pediatric patients and correlating with a greater rate of sinusitis, was observed in 2022.

Radiological differentiation between bacterial orbital cellulitis and invasive fungal sino-orbital infections.

PURPOSE: Invasive fungal orbital infections (IFOI) may be difficult to differentiate from sinogenic bacterial orbital cellulitis (OC). This study investigates the features differentiating OC from IFOI on magnetic resonance imaging (MRI). METHODS: Retrospective study of adult patients with sinogenic OC and IFOI with pre-intervention MRI. Patients without post-septal involvement, non-sinogenic OC (e.g.: secondary to trauma) and poor-quality scans were excluded. Independent Sample's t test and Fisher's exact test were conducted with p < 0.05 deemed statistically significant. RESULTS: Eleven cases each of OC (Mean age: 41.6 ± 18.4 years-old, Male: 10) and IFOI (Mean age: 65.0 ± 16.6 years-old, Male: 9) between 2006 and 2023. IFOI patients were older, more likely immunocompromised and had a lower mean white-cell count (p value = 0.005, 0.035 and 0.017, respectively). The ethmoid and maxillary sinuses were most commonly involved in both entities. Pre-septal and lacrimal gland involvement were more common in OC (p = 0.001 and 0.008, respectively). Infiltrative OC orbital lesions were poorly demarcated, whilst those in IFOI were expansile/mass-like invading the orbit from the adjacent paranasal sinuses. Specific IFOI features included loss-of-contrast-enhancement (LoCE) of paranasal sinus tissues with orbital extension. Extra-orbital and -sinonasal extension indicative of IFOI included contiguous skull base or pterygopalatine fossa involvement, retro-antral and masticator space stranding and vasculitis. CONCLUSION: This study describes the key MRI features of IFOI including differentiating markers from OC. These specific features, such as LoCE of the paranasal and orbital soft tissues, the location and pattern of contiguous soft-tissue involvement, provide expedient identification of IFOI which necessitate early surgical intervention for microbiological confirmation of an invasive fungal pathology.

Qualitative and Quantitative Magnetic Resonance Imaging in Bacterial Orbital Cellulitis.

PURPOSE: To summarise the qualitative and quantitative parameters of bacterial orbital cellulitis (OC) on magnetic resonance imaging (MRI) and explore their clinical correlations. METHODS: Multi-centre retrospective study with inclusion of patients of all ages with OC who underwent MRI. Patients with isolated pre-septal cellulitis, bilateral disease and poor-quality scans were excluded. An enlargement ratio for extraocular muscles (EOMs) was calculated by dividing maximal EOM measurements from the affected side by the contralateral side. RESULTS: Twenty MRI scans from twenty patients (Mean age: 40.8 ± 24.3 years old, M: F = 15:5) between 2011 and 2022 were analysed. Three (15.0%) cases were paediatric patients (<18 years old). All cases had both pre-septal and orbital fat involvement. The EOM were affected in nineteen cases, with the superior muscle complex (18/19, 94.7%) most commonly affected. Mean enlargement ratio (1.30, Range: 1.04-1.82) was greatest for the medial rectus on axial views on T1 and fat-suppressed contrast-enhanced T1 (FS CE T1). Optic peri-neuritis was present in eleven (55.0%) patients, whilst two (9.5%) cases had optic neuritis. A greater degree of proptosis was observed in patients with optic neuropathy and those who underwent surgical intervention compared to those without (p = .002 and p = .002, respectively). CONCLUSION: MRI remains an important imaging modality for evaluating complicated OC. However, qualitative features may lack accuracy and is not a reproducible means of analysis. Simple quantitative parameters, such as proptosis and EOM measurements, correlate with high-risk clinical features and may have utility in predicting clinical course.

A Case of Epstein-Barr Virus Encephalitis and Orbital-Face Inflammation.

Epstein-Barr virus (EBV) can cause follicular conjunctivitis, keratitis, oculoglandular syndrome, meningitis, and encephalitis. We report a 54-year-old Hispanic male who presented with right pupil-involved complete ophthalmoplegia, orbital and masticatory muscle inflammation, trigeminal enhancement, and new corneal infiltrate highly suggestive of EBV. Labwork was negative except for positive EBV polymerase chain reaction (PCR) in serum. Magnetic resonance imaging (MRI) of his brain and orbits with contrast showed enhancement of the right ganglion of the trigeminal nerve, oculomotor nerve, all extraocular muscles in the right orbit, and right masticatory and temporalis muscles and a right subacute lacunar infarct. The patient was diagnosed with encephalitis and orbital-face inflammation secondary to EBV infection. The patient improved with systemic steroids.

Finegoldia magna and Mucorales molds co-infection in a severe case of SARS-CoV-2 disease.

INTRODUCTION: Rhino-orbito-cerebral mucormycosis has been reported as a sequela after coronavirus disease in immunocompromised patients with poorly controlled diabetes mellitus. Most cases have been identified in India, with only 19 reported elsewhere. METHODOLOGY: We herein report the results of clinical, imaging, microbiological, and histopathological studies in an immunocompetent 67-year-old male with rhino-orbital infection by Finegoldia magna and Mucorales molds following severe SARS-CoV-2 disease associated with new-onset decompensated diabetes mellitus. RESULTS: Microbiological and histological studies confirmed the presence of both Mucorales molds and Finegoldia magna, which was successfully treated with antibiotics and a specific anti-fungal agent (Posaconazole). CONCLUSIONS: Careful multidisciplinary follow-up of patients treated for severe SARS-CoV-2 disease is necessary for the timely diagnosis of complications such as uncontrolled diabetes mellitus and opportunistic infections.

Does Adenoid Hypertrophy Increase the Risk of Orbital Complication in Children with Acute Sinusitis?

Adenoid hypertrophy (AH) plays a role as a reservoir for bacterial growth and decreases mucociliary clearance which might contribute to the development of an infection. To compare the presence of AH in the pediatric population presenting with orbital complications as a result of ABRS and the control group radiologically. Patients who were diagnosed with OC as a result of ABRS labeled as case group, and the patients who had undergone computed tomography (CT) for indications other than sinonasal diseases were assigned as control group. Both groups were retrospectively reviewed to measure the adenoid, nasopharynx, and adenoid/nasopharynx ratio (ANR) in the axial and mid-sagittal planes. We compared 52 patients from case group to 57 control group. In the CT axial plane, adenoid length was greater in the OC group compared to the control group, with a significant difference (p-value = 0.02) of 14.2 ± 3.5 mm compared to 11.2 ± 7 mm, respectively. The ANRs were 2.9 in the OC group and 2.8 in the control group, with a p-value of 0.089. In the mid-sagittal plane, only the anteroposterior length was significantly greater in the OC group, with a mean of 19.9 ± 5.3 mm compared to 15.2 ± 8.8 mm in the control group (p-value = 0.007). The process of inflammation increased the anteroposterior length of the adenoids. However, the ANR was similar between the two groups, indicating that adenoid hypertrophy is not directly related as a risk factor for OC in pediatric patients with ARBS.

A case of orbital cryptococcosis.

Purpose: This report describes a case of Cryptococcus neoformans found in an unlikely location, the orbit, in an apparently immunocompetent host. Observations: A coordinated, multi-disciplinary approach between the ophthalmology, neurosurgery, pathology, and infectious disease departments was integral to saving both vision and life. Conclusions and Importance: This is the first case of primary orbital cryptococcosis described in the medical literature, to the authors' knowledge. The case draws attention to the possibility that Cryptococcus neoformans can indeed invade the orbit and should be considered part of the differential diagnosis for patients presenting with orbital masses of uncertain etiology.

Orbital Onslaught: An Atypical Presentation of Mucormycosis in a Diabetic and Hypertensive Patient.

Mucormycosis, primarily known to affect the sinuses and brain, severely threatens immunocompromised individuals. Its occurrence in the orbital region is rare and potentially devastating. We report a unique case of a 50-year-old male with longstanding diabetes and hypertension who exhibited isolated orbital mucormycosis confined to the right eye. The patient presented with fever and acute vision loss without classic sinusitis symptoms; earlier mismanagement led to an aggressive relapse. An orbital computed tomography (CT) scan revealed inflammatory changes indicative of an early-stage invasive fungal infection. Comprehensive management involving surgical debridement and antifungal therapy successfully halted intracranial spread and further complications. This case underscores the necessity for high clinical vigilance in diagnosing atypical presentations of mucormycosis in susceptible populations, advocating for a rapid, multidisciplinary approach to ensure optimal outcomes. It also adds to the existing literature on the myriad manifestations of this formidable fungal infection.

Orbital Aspergillosis, a great masquerader: a series of three unusual cases and a review of the literature.

Fungal infections of the orbit are infrequent. They typically affect immunocompromised individuals but, in some instances, can also affect an immunocompetent person. They mimic much orbital pathology clinically. Ours is a series of three patients eventually diagnosed with orbital aspergillosis but who, initially, were thought to have some other pathology.

Orbital abscess: 20 years' experience at a tertiary eye care center.

PURPOSE: To study the clinical, microbiological profile and management outcomes of orbital abscess at a tertiary care center in South India. MATERIAL AND METHOD: In a retrospective interventional case series, we reviewed all patients diagnosed with orbital cellulitis from 2000-2020. The data analyzed included demographic profile, clinical and radiological features, microbiological profile, and management outcome. RESULTS: A total of 921 cases of orbital and periorbital infections were reviewed. Seventy-two cases were diagnosed as orbital cellulitis. Thirty-four cases (47.22%) had radiological evidence of orbital abscess. The median age was 20.63 years. Three patients (8.82%) were neonates. A male preponderance was noted (23, 67.65%). Sinusitis (10, 29.41%) and diabetes (5, 14.7%), were the most common predisposing factors. Optic neuropathy was seen in 15 (44.11%) patients, cavernous sinus thrombosis in two patients (5.88%), and septicemia in one patient (2.94%) Multiple orbital abscesses were noted in 7 (20.59%) cases. All patients underwent surgical drainage. Methicillin-sensitive Staphylococcus aureus was the most common organism isolated in 14 patients (41.18%). Vision improvement or stabilization was seen in all except 3 (8.82%). CONCLUSION: Orbital abscess is a potential sight-threatening orbital infection. The infective process can spread and ascend up to involve cavernous sinus thereby becoming life-threatening. A timely diagnosis and intervention can halt the disease process and help restore vision in many cases.

A 10-year-old immunocompetent girl with endogenous fungal endophthalmitis: Report of a case and review of the literature.

Endogenous Endophthalmitis (EE) is a rare cause of blindness in the pediatric age group and this may account for the paucity of management guidelines in the literature. In this report, we describe our experience with a 10-year-old immunocompetent female who developed EE and became blind because of rapidly progressive and destructive inflammatory changes in her eye in spite of seemingly timely treatment.

Mucormycosis in patients with COVID-19: A cross-sectional descriptive multicentre study from Iran.

PURPOSE: The aim of the study was to report clinical features, contributing factors and outcome of patients with coronavirus disease 2019 (COVID-19)-associated mucormycosis (CAM). METHODS: A cross-sectional descriptive multicentre study was conducted on patients with biopsy-proven mucormycosis with RT-PCR-confirmed COVID-19 from April to September 2020. Demographics, the time interval between COVID-19 and mucormycosis, underlying systemic diseases, clinical features, course of disease and outcomes were collected and analysed. RESULTS: Fifteen patients with COVID-19 and rhino-orbital mucormycosis were observed. The median age of patients was 52 years (range 14-71), and 66% were male. The median interval time between COVID-19 disease and diagnosis of mucormycosis was seven (range: 1-37) days. Among all, 13 patients (86%) had diabetes mellitus, while 7 (46.6%) previously received intravenous corticosteroid therapy. Five patients (33%) underwent orbital exenteration, while seven (47%) patients died from mucormycosis. Six patients (40%) received combined antifungal therapy and none that received combined antifungal therapy died. CONCLUSION: Clinicians should be aware that mucormycosis may be complication of COVID-19 in high-risk patients. Poor control of diabetes mellitus is an important predisposing factor for CAM. Systematic surveillance for control of diabetes mellitus and educating physician about the early diagnosis of CAM are suggested.

Etiologies of Proptosis: A review.

Proptosis, the protrusion of the eyeball from the orbit, results from a wide variety of pathologies that can be vision- or life-threatening. Clinical history, associated physical exam findings, and imaging features are all crucial in establishing the underlying etiology. The differential diagnosis is broad, and includes infectious, inflammatory, vascular, and neoplastic entities that range from benign and indolent, to malignant and aggressive. While treatment varies significantly based on the disease process, all are aimed at preserving vision, salvaging the globe, preventing disfigurement, and reducing mortality. Both internists and general ophthalmologists should be familiar with the causes of proptosis in order to initiate the work-up for, and appropriately triage, affected patients.

Hospital utilization for orbital and intracranial complications of pediatric acute rhinosinusitis.

BACKGROUND: Orbital and intracranial complications of pediatric acute rhinosinusitis (ARS) are uncommon. With a risk of significant morbidity, hospital utilization and the financial burden of these entities are often high. We sought to assess utilization trends for complicated ARS and elucidate which factors influence cost. METHODOLOGY: Analysis of Kids' Inpatient Database (2006, 2009 and 2012). Children were selected based on diagnosis codes for ARS and grouped as: uncomplicated ARS, orbital complications (OC), or intracranial complications (IC). Patients with IC were subdivided into abscess (ICa), meningitis, or sinus thrombosis. Length of stay (LOS), cost and management information were analysed. Data presented as median [IQR]. RESULTS: A weighted total of 20,775 children were included. OC and IC were observed in 10.9% and 2.7% of these patients. LOS was longer for IC compared to OC (9 [8] v 4 [3]days, p < 0.001). Daily cost for IC was greater than OC ($2861 [4044] v $1683 [1187], p < 0.001), likely due to differences in need for surgery (IC 66.3% v OC 37.1%, p < 0.001). Within the ICa group, patients who received both otolaryngologic (ENT) and neurosurgery, compared to neurosurgery alone, had higher total cost ($41,474 [41,976] v $32,299 [18,235], p < 0.001) but similar LOS (12 [10] v 11 [9] days, p = 0.783). CONCLUSIONS: Children with IC required more surgery than their OC counterparts, resulting in a longer LOS and increased cost. Within the ICa group, the addition of ENT surgery to neurosurgery resulted in higher costs, but with a similar LOS. Considering the increased costs, the additional benefit of ENT surgery to those with children with IC should be investigated further.

Trends in complications of pediatric rhinosinusitis in the United States from 2006 to 2016.

OBJECTIVES: 1) Evaluate the changing prevalence of complications from pediatric acute bacterial rhinosinusitis and 2) elucidate factors associated with the development of complicated acute rhinosinusitis in this population. STUDY DESIGN/SETTING: Cross-sectional analyses of the Kids' Inpatient Database. SUBJECTS AND METHODS: Children <20 years with a diagnosis of acute rhinosinusitis were included. Diagnosis codes pertaining to acute rhinosinusitis-related complications were then queried for each subject. All patients were ultimately categorized into one of four groups: uncomplicated acute rhinosinusitis, orbital complications, intracranial complications, or both orbital and intracranial complications. Weighted measures were applied to provide national estimates. RESULTS: Over the decade studied, national estimates for children admitted with acute rhinosinusitis decreased from 8,312 cases in 2006 to 5,592 in 2016. There was an increase in the rate of orbital complications from 8.9% to 19.3% and intracranial complications from 2.2% to 4.3%. Children with both complications increased from 0.5% to 1.0% of cases. Children with orbital complications were significantly younger (8.6 years) compared to those with intracranial complications (12.4 years) and both complication types (12.2 years) (p < 0.001). CONCLUSION: Despite an overall decrease in cases of acute rhinosinusitis, rates of orbital and intracranial complications continued to increase over a ten-year period. Antibiotic prescribing patterns, vaccination effects, and evolving practice patterns may help explain these observations. Further studies warrant investigation into the cause of these trends. LEVEL OF EVIDENCE: 4.

Orbital and intracranial Nocardia farcinica infection caused by trauma to the orbit: a case report.

BACKGROUND: Localized `and disseminated Nocardia farcinica infection is frequently reported in immunocompromised patients. However, orbital nocardiosis is rare, and, to our knowledge, traumatic orbital nocardiosis that affects the brain has never been described. Here, we report a case of traumatic orbital and intracranial N. farcinica infection in an immunocompetent patient. CASE PRESENTATION: A 35-year-old man, who was immunocompetent, to the best of our knowledge and as per the absence of immunodeficiency symptoms, with orbital trauma caused by the penetration of a rotten bamboo branch developed lesions in the orbit and brain. Subsequently, he underwent debridement and received broad-spectrum antibiotic therapy, but orbital infection occurred, with drainage of pus through the sinus tract. The patient then underwent endoscope-assisted local debridement. Bacterial culture of the sinusal pus was positive for N. farcinica, and a combined intracranial infection had developed. The disease was treated effectively by trimethoprim-sulfamethoxazole and ceftriaxone sodium therapy. The patient remained infection free and without complications at the 14-month follow-up. CONCLUSIONS: Traumatic orbital and intracranial infection caused by N. farcinica is a rare infectious disease, and atypical presentations easily lead to misdiagnosis. When a patient presents with an atypical orbital infection that is unresponsive to empirical broad-spectrum antibiotics, along with suspicious neurologic symptoms, Nocardia infection should be considered. Identification by bacterial culture is the gold standard. Complete local debridement and appropriate antibiotic treatment are keys to the treatment of the disease.

Outcomes and factors affecting them in patients with rhino-orbito-cerebral mucormycosis.

AIM: To report the frequency and factors affecting patients', globe and vision survivals in rhino-orbito-cerebral mucormycosis (ROCM). METHODS: This is a retrospective study of 63 patients (79 eyes) with biopsy-proven ROCM at a university hospital 2008-2016. Systemic and ophthalmic manifestations, imaging, management and final outcomes were recorded. Globe survival was defined as no exenteration and vision survival as final visual acuity of light perception and more. RESULTS: Mean age was 55.5 (SD 12.9) years with no gender preference. Diabetes was the most common underlying disease (68.3%). Patient survival was observed in 57.1 % (36/63). Presence of frozen eye (OR 4.6), nasal mucosal involvement (OR 7.3) and shorter duration of antifungal therapy (OR 1.03) were significantly associated with lower patient survival. Exenteration did not significantly change the survival. Globe survival was detected in 43% (34/79). Higher white blood cell (WBC) count was associated with a lower globe survival (p=0.02). Vision survival was observed in 25.3% (20/79) in whom younger age was significantly associated with a worse vision survival. CONCLUSION: Patient, globe and vision survivals were 57%, 43% and 25%, respectively. Exenteration did not affect the patients' survival. While frozen eye and nasal mucosal involvement were significantly associated with a lower survival, higher WBC count significantly increased the risk of exenteration.

Orbital infections: a complete cycle 7-year audit and a management guideline.

OBJECTIVES: Orbital infections are regularly encountered and are managed by various healthcare disciplines. Sepsis of the orbit and adjacent tissues can be associated with considerable acute complication and long-term sequelae. Therefore, prompt recognition and management of this condition are crucial. This article presents the outcomes of a 7-year complete cycle audit project and describes the development of the new local guideline on the management of orbital infections in our tertiary centre. METHODS: (1) A retrospective 5-year audit cycle on patients with orbital infections. (2) A review of available evidence on the management of orbital infections. (3) A new local multidisciplinary guideline on the management of orbital infections. (4) A retrospective 2-year second audit cycle to assess the clinical outcomes. RESULTS: Various disciplines intersect in the management of orbital infections. Standardising the management of this condition proved to be achievable through the developed guideline. However, room for improvement in practice exists in areas such as the promptness in referring patients to specialist care, the multidisciplinary assessment of patients on admission, and the improvement of scanning requests of patients.