Epidemiology, clinical presentation and management of COVID-19 associated mucormycosis: A single centre experience from Pune, Western India.

BACKGROUND: The second COVID-19 wave in India has been associated with an unprecedented increase in cases of COVID-19 associated mucormycosis (CAM), mainly Rhino-orbito-cerebral mucormycosis (ROCM). METHODS: This retrospective cohort study was conducted at Noble hospital and Research Centre (NHRC), Pune, India, between 1 April, 2020, and 1 August, 2021, to identify CAM patients and assess their management outcomes. The primary endpoint was incidence of all-cause mortality due to CAM. RESULTS: 59 patients were diagnosed with CAM. Median duration from the first positive COVID-19 RT PCR test to diagnosis of CAM was 17 (IQR: 12,22) days. 90% patients were diabetic with 89% having uncontrolled sugar level (HbA1c >7%). All patients were prescribed steroids during treatment for COVID-19. 56% patients were prescribed steroids for non-hypoxemic, mild COVID-19 (irrational steroid therapy), while in 9%, steroids were prescribed in inappropriately high dose. Patients were treated with a combination of surgical debridement (94%), intravenous liposomal Amphotericin B (91%) and concomitant oral Posaconazole (95.4%). 74.6% patients were discharged after clinical and radiologic recovery while 25.4% died. On relative risk analysis, COVID-19 CT severity index ≥18 (p = .017), presence of orbital symptoms (p = .002), presence of diabetic ketoacidosis (p = .011) and cerebral involvement (p = .0004) were associated with increased risk of death. CONCLUSIONS: CAM is a rapidly progressive, angio-invasive, opportunistic fungal infection, which is fatal if left untreated. Combination of surgical debridement and antifungal therapy leads to clinical and radiologic improvement in majority of cases.

Orbital cellulitis secondary to sinusitis in upstate New York: current incidence, seasonality, severity, management and outcomes.

PURPOSE: While sinusitis carries a seasonal variation, the temporal features of sinusitis-related orbital cellulitis (SRC) are unclear. This study analyzes the incidence, seasonality, management, and outcomes of SRC in northeastern New York. METHODS: A retrospective review of 79 patients was performed from January 2008 - December 2018. Cases of orbital cellulitis without comitant sinusitis were excluded. Demographic, radiographic, clinical features, month at presentation, interventions (surgical and nonsurgical), microbiology, and hospitalization duration were recorded. Fisher-exact test, Mann-Whitney test, and Kruskal Wallis test statistical analyses were performed in consultation with our institution's statistician via a dedicated software package (vassarstats.net). RESULTS: 79 patients were admitted for SRC. 25 patients were treated with antibiotics only, 31 underwent orbitotomy exclusively and 23 received combined orbitotomy and functional endoscopic sinus surgery (FESS). Of the 31 patients who underwent orbitotomy only, 8 (26%) returned to the operating room. In contrast, of those who underwent concomitant orbitotomy and FESS, only one patient (4.3%) required re-operation (fisher exact test, p = .021). The median length of stay for the antibiotic-only group (4 days), orbitotomy-only group (6 days), and combined surgery group (5 days) were statistically different (Kruskal Wallis, p = .004, Figure 3). Interestingly, there was no significant relationship of incidence or severity of SRC related to seasonality (fisher-exact test, p = .76). CONCLUSION: Our findings suggest that cases requiring surgical management for SRC should undergo coinitial orbitotomy with FESS to reduce re-operation rates. Additionally, SRC incidence and severity did not correlate with season.

[Risk management of the diagnosis and treatment of orbital disease].

In recent years, orbital disease has received considerable attention and developed rapidly. It is both an opportunity and a challenge to carry out the construction of orbital disease subspecialty scientifically and efficiently. This article focuses on the necessity of establishing a subspecialty department, the particularity and complexity of orbital disease, and how to effectively perform clinical work. The large quantity of potential patients and the urgent requirement of comprehensive academic progress give rise to the necessity of developing the orbital disease subspecialty. The difficulty of diagnosis and the high risk of operation in orbital disease place emphases on specialist allocation and personnel training. The equipment support and specialist training should go hand in hand, requiring professionals to have strong pressure resistance ability and solid theoretical knowledge, so as to ensure stable, efficient and sustainable development of the orbital disease subspecialty. (Chin J Ophthalmol, 2021, 57: 805-808).

Epidemiology, clinical profile, management, and outcome of COVID-19-associated rhino-orbital-cerebral mucormycosis in 2826 patients in India - Collaborative OPAI-IJO Study on Mucormycosis in COVID-19 (COSMIC), Report 1.

Purpose: COVID-19-associated rhino-orbital-cerebral mucormycosis (ROCM) has reached epidemic proportion during India's second wave of COVID-19 pandemic, with several risk factors being implicated in its pathogenesis. This study aimed to determine the patient demographics, risk factors including comorbidities, and medications used to treat COVID-19, presenting symptoms and signs, and the outcome of management. Methods: This was a retrospective, observational study of patients with COVID-19-associated ROCM managed or co-managed by ophthalmologists in India from January 1, 2020 to May 26, 2021. Results: Of the 2826 patients, the states of Gujarat (22%) and Maharashtra (21%) reported the highest number of ROCM. The mean age of patients was 51.9 years with a male preponderance (71%). While 57% of the patients needed oxygen support for COVID-19 infection, 87% of the patients were treated with corticosteroids, (21% for > 10 days). Diabetes mellitus (DM) was present in 78% of all patients. Most of the cases showed onset of symptoms of ROCM between day 10 and day 15 from the diagnosis of COVID-19, 56% developed within 14 days after COVID-19 diagnosis, while 44% had delayed onset beyond 14 days. Orbit was involved in 72% of patients, with stage 3c forming the bulk (27%). Overall treatment included intravenous amphotericin B in 73%, functional endoscopic sinus surgery (FESS)/paranasal sinus (PNS) debridement in 56%, orbital exenteration in 15%, and both FESS/PNS debridement and orbital exenteration in 17%. Intraorbital injection of amphotericin B was administered in 22%. At final follow-up, mortality was 14%. Disease stage >3b had poorer prognosis. Paranasal sinus debridement and orbital exenteration reduced the mortality rate from 52% to 39% in patients with stage 4 disease with intracranial extension (p < 0.05). Conclusion: : Corticosteroids and DM are the most important predisposing factors in the development of COVID-19-associated ROCM. COVID-19 patients must be followed up beyond recovery. Awareness of red flag symptoms and signs, high index of clinical suspicion, prompt diagnosis, and early initiation of treatment with amphotericin B, aggressive surgical debridement of the PNS, and orbital exenteration, where indicated, are essential for successful outcome.

MR-Eye: High-Resolution Microscopy Coil MRI for the Assessment of the Orbit and Periorbital Structures, Part 2: Clinical Applications.

In the first part of this 2-part series, we described how to implement microscopy coil MR imaging of the orbits. Beyond being a useful anatomic educational tool, microscopy coil MR imaging has valuable applications in clinical practice. By depicting deep tissue tumor extension, which cannot be evaluated clinically, ophthalmic surgeons can minimize the surgical field, preserve normal anatomy when possible, and maximize the accuracy of resection margins. Here we demonstrate common and uncommon pathologies that may be encountered in orbital microscopy coil MR imaging practice and discuss the imaging appearance, the underlying pathologic processes, and the clinical relevance of the microscopy coil MR imaging findings.

Cost comparison between surgical and conservative management for pediatric sinogenic subperiosteal abscesses.

BACKGROUND: There remains variation in management of orbital complications of acute bacterial rhinosinusitis (ABRS); specifically, those subperiosteal abscesses that present without immediate surgical indication. Recent systematic reviews on management and proposed treatment algorithms are helpful but do not consider the financial implications for healthcare systems and patients. METHODS: A retrospective chart review of pediatric patients from a tertiary care children's hospital between 2002 and 2020 was performed, identifying patients via ICD coding corresponding to acute bacterial sinusitis and orbital involvement classified as Chandler 3 confirmed by contrasted computed tomography (CT). Two groups of patients were identified: intravenous (IV) antibiotics alone and IV antibiotics plus surgery. Billing records of total hospital charges and physician fees were recorded for financial analysis. Demographic, length of stay, and charges were analyzed. RESULTS: 58 patients with ABRS and Chandler 3 orbital involvement were confirmed by CT imaging. Twenty-nine (50%) were treated with IV antibiotics alone, and twenty-nine (50%) underwent surgery in addition to IV antibiotics. There were no significant differences in patient demographics. The average total hospital charges for the medically managed group were $9262 ± 4831 compared to $30,830 ± 11,397 for the surgical group (p < 0.0001). In the medically managed group, the average hospital fees were $7305 ± 4048 and the average physician fees were $1543 ± 799. In the surgical group, the average hospital and physician fees were also significantly higher at $23,071 ± 7305 (p < 0.0001) and $7763 ± 3335 (p < 0.0001), respectively. Patients who were treated medically and had a longer than average LOS still had significantly fewer charges than those treated with antibiotics plus surgery and a shorter than average length of stay [$15,311 and $27,723, respectively (p = 0.02)]. CONCLUSION: Pediatric ABRS with orbital involvement requires prompt attention and management. Controversy persists over subperiosteal abscess management that present without overt surgical indications. Surgical intervention is expensive. Our subgroup analysis demonstrates the magnitude of this cost difference. Specifically, longer inpatient stays with IV antibiotics alone appear to be significantly cheaper than shorter ones that include surgery. Not all Chandler 3 patients are candidates for non-surgical management; however, clinicians are encouraged to keep these data in mind for those patients where further medical management is safe and may yield less expensive clinical resolution.

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.

Prolapse of Orbital Fat through the Inferior Orbital Fissure: Description, Prevalence, and Assessment of Possible Pathologic Associations.

BACKGROUND AND PURPOSE: A few patterns of orbital fat prolapse have been described. Some are associated with disease, and others may mimic a neoplasm. We have observed prolapse of orbital fat into the infratemporal fossa via the inferior orbital fissure on MR imaging. The clinical relevance of this finding, if any, is unknown. The purposes of this study were to describe the MR imaging appearance of orbital fat prolapse through the inferior orbital fissure, to estimate the prevalence of this finding, and to assess possible pathologic associations. MATERIALS AND METHODS: For this retrospective study of 228 orbital MR imaging examinations, 3 neuroradiologists independently assessed the presence of prolapse on high-resolution T1-weighted images. Discrepancies were resolved by consensus, and interobserver agreement was calculated. Patient demographics, indications for imaging, and pertinent clinical history were recorded. One-way analysis of variance and the Fisher exact test were used to assess possible associations between prolapse and specific patient characteristics. RESULTS: Orbital fat prolapse through the inferior orbital fissure was observed in 20/228 patients (9%). This finding was unilateral in 11 patients (55%) and bilateral in 9 patients (45%). There was no significant association with age, sex, obesity, Graves disease, hypercortisolism, prior orbital trauma, proptosis, or enophthalmos. Interobserver agreement was 90%. CONCLUSIONS: Prolapse of orbital fat into the infratemporal fossa via the inferior orbital fissure is a relatively common finding on orbital MR imaging that has no identified pathologic association. Neuroradiologists should recognize this finding so as not to report it as pathologic.

Endoscopic versus external dacryocystorhinostomy: temporal and regional trends in the United States Medicare population.

Purpose: Endoscopic surgeries, such as dacryocystorhinostomy (DCR), are increasingly performed for orbital and lacrimal conditions. This study describes and compares recent trends in endoscopic DCR with open, or external, DCR in the United States (US). Methods: Medicare-Part-B National Summary data files were analyzed from 2000 to 2015 for temporal and geographic trends in endoscopic and external DCR. Medicare Physician and Other Supplier public use files detailing provider information were collected and analyzed from 2012 to 2015. Results: Between 2000 and 2015, the number of external DCRs remained relatively unchanged (8008 to 7086, -0.7% average annual growth), while the number of endoscopic DCRs steadily increased (881 to 1674, 4.6% average annual growth). The greatest number of endoscopic DCRs were performed in the South Atlantic region, whereas the Mountain region had the greatest number per capita. From 2000 to 2015, the average payment per procedure for external DCR was $526.63, compared with $512.45 for endoscopic DCR. Of endoscopic DCRs performed from 2012 to 2015, 831 (79%) were performed by Ophthalmology, 184 (18%) were performed by Otolaryngology, and the remainder by other subspecialties. Conclusions: The number of endoscopic DCR surgeries increased over the last 15 years while the number of external DCR surgeries remained stable and continued to surpass endoscopic procedures. While ophthalmologists perform the overwhelming majority of endoscopic DCR, otolaryngologists are performing a growing number.

Orbital Implants in Enucleation Surgery: A Report by the American Academy of Ophthalmology.

PURPOSE: To compare the motility and complication rates of porous and nonporous implants after enucleation surgery. METHODS: Literature searches of the PubMed and Cochrane Library databases were last performed in February 2017 to identify studies published between 2003 and 2017 on outcomes after enucleation surgeries in which a variety implants were used. The searches were limited to the English language with abstracts and yielded 43 articles, which the Ophthalmic Technology Assessment Committee Oculoplastics and Orbit Panel reviewed for relevancy. Twenty-five articles were considered to have met the search strategy, and the panel methodologist assigned ratings to them according to the level of evidence. RESULTS: Only 2 of the 25 articles identified met the criteria for level I evidence. Eighteen of the studies did not assess motility after enucleation surgery, and the 7 that did evaluate this metric involved porous implants. The studies that analyzed this outcome reported favorable results, but the results were not uniformly based on objective analysis. Both porous and nonporous implants were well tolerated, and complication rates were generally low for both types. CONCLUSIONS: In keeping with increasing surgeon preference for porous implants, most studies identified in this literature search involved the use of this type of implant. These implants resulted in excellent motility after enucleation surgery, although many studies did not assess this outcome. Regardless of implant type, major complications were rare, and infection was exceptionally uncommon after enucleation. Given the paucity of data on motility and the absence of direct, objective comparisons of porous and nonporous implants, definitive conclusions about the impact of implant material on motility cannot be made. Since few studies evaluated nonporous implants, direct comparisons cannot be made definitively between implant types, and future investigations are needed to enable a critical assessment.

Use of 3D orbital reconstruction in the assessment of orbital sexual dimorphism and its pathological consequences.

INTRODUCTION: Surrounded by a variety of structures including the facial sinuses and the brain, the human orbit displays unique anatomical features. It is known that orbital volume correlates with age and sex. The aim of this study was to evaluate sexual dimorphism of orbital volume relative to the size of the skull, and to establish criteria for gender determination. METHODS: Orbital volume was measured from 3D models of the orbits. The volumes were expressed in relation to the centroid size of the skull, to ensure that any sexual dimorphism in orbital volume was not simply due to a difference in skull size. Thirty-three male and 42 female subjects were included in the study. RESULTS: The volume of both orbits were significantly higher in men than in women (P=0.0001). The right, left and total orbital volumes relative to the centroid skull size were also significantly higher in men than women (P<0.05). The method was repeatable and reproducible. A test of gender determination was developed, with a precision of 77.3%. DISCUSSION: This is the first study showing a sexual dimorphism in orbital volume relative to skull size. This difference in volume could explain the greater predisposition to myopia in women and their more frequent need for orbital decompression in thyroid orbitopathies.

The "tight orbit": Incidence and management of the orbital compartment syndrome.

PURPOSE: The orbital compartment syndrome (OCS) constitutes a severe emergency, requiring immediate clinical diagnosis and surgical decompression. The key symptom is progressive visual impairment caused by an increase in intraorbital pressure, impairing the perfusion of relevant neurovascular and neurosensory structures. Intraorbital bleeding due to trauma and surgical intervention is known to be the main etiological factor. MATERIAL AND METHODS: A retrospective analysis of all patients affected by an OCS between January 1, 2012, and May 31, 2015, was performed. Patients' records were reviewed with regard to etiology, initial ophthalmologic status, fracture pattern, concomitant medication, surgical management, and postoperative outcome. The incidence of OCS was calculated based on the total number of craniomaxillofacial (CMF) emergencies. RESULTS: Within 3.5 years, a total of 18,093 CMF emergencies were registered. In 16 patients, an OCS was documented, corresponding to an incidence of 0.088%. The mean patient age was 67.31 ± 23.86 years, ranging from 22 to 102 years. The etiology varied, but trauma with subsequent intraorbital bleeding was the main cause. The use of anticoagulative medication was documented in 50% of the cases. In 14 patients, immediate surgical orbital decompression was performed: in 10 patients, vision could be preserved; in three patients, blindness resulted; and one patient was lost to follow-up. Two patients were managed without surgery. CONCLUSION: With regard to the total number of CMF emergencies, OCS is a rare condition. Early clinical diagnosis and surgical decompression are required to prevent permanent vision impairment. Anticoagulative medication must be considered as a predisposing factor for an orbital compartment syndrome in patients affected by periorbital trauma.

Diagnostic performance of isolated orbital CT scan for assessment of globe rupture in acute blunt facial trauma.

OBJECTIVES: We determine the diagnostic performance of emergent orbital computed tomography (CT) scans for assessing globe rupture in patients with blunt facial trauma. METHODS: We performed a retrospective cohort study based on prospectively collected trauma registry and acute care surveillance data in a tertiary-care hospital. Patients aged at least 18 years who underwent isolated orbital CT scanning for assessing potential ocular trauma were examined. Analyses were performed to evaluate the magnitude of agreement between diagnosis by CT scanning and ophthalmic assessment, including globe rupture. RESULTS: Our study cohort comprised 136 patients, 30% of whom (41 patients) sustained orbital wall fractures. Concordance for orbital CT diagnosis and the ophthalmic assessment of globe rupture was substantial (k=0.708). The relative risk of globe rupture was 0.692 (95% confidence interval (CI): 0.054-8.849) for superior wall fractures, 0.459 (95% CI: 0.152-1.389) for inferior wall fractures, 2.286 (95% CI: 1.062-4.919) for lateral wall fractures, and 0.637 (95% CI: 0.215-1.886) for medial wall fractures. According to multivariate analysis, lateral wall fractures were an independent risk factor for globe ruptures (adjusted odds ratio (OR)=12.01, P=0.011), and medial or inferior wall fracture was a protective factor (adjusted OR=0.14, P=0.012). In the stratified analysis of diagnostic performance of CT scan, specificity was highest among patients with orbital wall fractures (97.2%), followed by negative predictive volume (NPV, 97%), and accuracy (95.1%). CONCLUSION: Among patients with blunt facial trauma who underwent isolated orbital CT scanning as part of ocular trauma assessment, the diagnostic performance of CT in detecting globe rupture is more accurate in patients with orbital wall fractures. Nevertheless, isolated orbital CT alone does not have a sufficiently high diagnostic performance to be reliable to rule out all globe ruptures. Lateral orbital wall fractures in blunt facial trauma patients, in particular, should prompt thorough evaluation by an ophthalmologist.

Quantitative Assessment of Optic Nerve With Diffusion Tensor Imaging in Patients With Thyroid Orbitopathy.

PURPOSE: To detect abnormalities of the optic nerve in patients with thyroid orbitopathy using diffusion tensor MRI. METHODS: Twenty-eight patients with Graves orbitopathy prospectively underwent diffusion tensor imaging scanning. A full ophthalmic examination including visual acuity, intraocular pressure, fundoscopy, and visual field analysis was performed. Clinical activity scores were also calculated. Fractional anisotropy (FA) and mean diffusivity values of the patients were compared with age and sex-matched healthy control subjects. RESULTS: The mean FA values were decreased and mean diffusivity values were increased significantly in patients with Graves orbitopathy compared with the control subjects (p < 0.001). There was a strong reverse correlation between the FA levels and the visual fields in 4 quadrants of the optic nerve. In addition, there was a strong correlation between the degree of proptosis and the FA values in both eyes. The mean diffusivity levels were also correlated with changes in the visual field and the degree of proptosis. CONCLUSION: FA and mean diffusivity levels measured with the diffusion tensor imaging of the thyroid orbitopathy patients were affected. The changes in diffusion tensor imaging were also correlated with the ophthalmologic tests of the patients.

Trends in orbital complications of pediatric rhinosinusitis in the United States.

IMPORTANCE: Several studies have documented the prevalence and treatment of orbital complications secondary to pediatric rhinosinusitis, but to our knowledge, none have investigated the national health care burden of this disease since the introduction of the heptavalent pneumococcal vaccine (PCV-7). OBJECTIVE: To identify the current public health burden of orbital complications of pediatric rhinosinusitis, and to determine if the introduction of the PCV-7 has resulted in a change in national practice patterns. DESIGN, SETTING, AND PARTICIPANTS: Population-based study using the 2000 and 2009 Kids' Inpatient Databases to gather data on a sample of all pediatric discharges in the United States during the years 2000 and 2009. Children diagnosed as having orbital complications of sinusitis were identified by corresponding International Classification of Diseases, Ninth Revision (ICD-9) codes. Database analyses generated national estimates of summary statistics and comparison of trends over the 9-year period. INTERVENTIONS: Database analysis. MAIN OUTCOMES AND MEASURES: National health care trends according to year. End points assessed included prevalence, age, sex, length of hospital stay, and treatment of disease. RESULTS: The estimated prevalence of orbital complications of sinusitis requiring hospitalization in the United States has slightly decreased from 5338 (95% CI, 4956-5720) admissions in 2000 to 4511 (95% CI, 4165-4858) in 2009. However, the mean age has increased from 4.77 (95% CI, 4.56-4.97) years to 6.07 (95% CI, 5.87-6.26) years. The proportion of children undergoing surgical treatment increased from 0.108 (95% CI, 0.093-0.123) to 0.195 (95% CI, 0.176-0.213). Total charges increased from $4,140,000 (95% CI, $3,440,000-$4,830,000) to $10,000,000 (95% CI, $8,480,000-$11,600,000) with a mean charge per admission increasing from $8390 (95% CI, $7096-$9685) in 2000 to $22,656 (95% CI, $19,997-$25,314) in 2009. The mean length of stay remained stable at 3.67 (95% CI, 3.37-3.97) to 4.05 (95% CI, 3.81-4.29) hospital days. CONCLUSIONS AND RELEVANCE: The public health impact of orbital complications of pediatric rhinosinusitis continues to be substantial. Since the institution of the PCV-7 vaccine, national trends demonstrate a slightly decreased prevalence of hospital admissions. However, there is a shifting trend toward an older age at admission and a higher proportion of children undergoing surgical treatment.