Long-term outcomes of transcutaneous retrobulbar amphotericin B in COVID-19-associated mucormycosis

Abstract

Purpose: To describe the long-term outcomes of transcutaneous retrobulbar amphotericin B (TRAMB) in COVID-19-associated mucormycosis.

Methods: In total, 18 cases of COVID-19-associated mucormycosis were reviewed. In addition to the recommended treatment protocol, all patients were to be given 3.5 mg/ml/day of TRAMB for five days.

Results: Of the 18 patients, 2 presented with stage 3a disease, 13 had stage 3c disease, and 3 patients had central nervous system (CNS) involvement (stage 4a and 4c). In addition to planned retrobulbar doses, five patients were given more while two patients received fewer injections (i.e., <5). At the last mean follow-up of 34.67 (±8.88) weeks, 11 patients were in radiological regression and 4 had stable disease while 2 patients had to undergo exenteration; one mortality was observed because of disease progression. Clinical regression in terms of visual and ptosis improvement was seen in seven and nine patients, respectively.

Conclusion: Rhino-orbito-cerebral mucormycosis is a serious condition which warrants an aggressive treatment strategy. In unprecedented situations witnessed recently, TRAMB turned out to be an effective and economical alternative. Though large randomized studies are needed to establish its efficacy, TRAMB still manages to halt progression and salvage the globe in significant number of patients, and hence its use should be encouraged on a case-to-case basis especially in developing countries with limited resources.

Keywords: COVID-19; TRAMB; globe salvage; mucormycosis; regression.

Figure 1

(a-d) Pre- and post-TRAMB images of four patients showing improvement in ptosis after one week of injection

Figure 2

Pre- and post-TRAMB radiological changes in stage 4c disease [Pre-TRAMB (a–d)]. A T2W scan showing hypointense soft tissue in right intraconal space and orbital apex; diffusion restriction noted in intraconal optic nerve and cavernous sinus; a T1W coronal image with thrombosed right ICA with bulky and heterogenous cavernous sinus. [Post-TRAMB (e–h)]. A follow-up T1W scan at three months showing an organized hypointense tissue; resolution of diffusion restriction; a T1W scan showing organized heterogenous enhancement and reduced inflammatory changes; reduced bulk and heterogeneity of cavernous sinus