Treatment and Survival Outcomes in Rhino-Orbital Mucormycosis with and without Orbital Exenteration: A Retrospective Case Series and Literature Review

Abstract

Rhino-orbital mucormycosis (ROM) is a life-threatening, fungal infection, primarily affecting immunocompromised patients. The role of orbital exenteration in treatment remains debated, especially regarding its impact on survival outcomes. This case series presents two patients from our Ophthalmology department and compares them with eight cases from the literature, focusing on treatment outcomes and survival rates. We specifically explore the impact of orbital exenteration and other management strategies. The analysis reveals that survival outcomes are closely linked to the timely initiation of antifungal therapy, the patient's underlying conditions, and the extent of orbital involvement at the time of diagnosis. Our findings, in line with the literature, show that early-stage ROM can be treated successfully with less invasive methods, while advanced cases may require orbital exenteration. The need for exenteration should be evaluated on a case-by-case basis, with early detection and appropriate antifungal treatment being critical factors for survival. This study highlights the importance of early diagnosis and individualized treatment plans, emphasizing that while orbital exenteration may improve survival in severe cases, less invasive interventions should be considered for less advanced ROM. Further research and standardized guidelines are needed to refine treatment strategies.

Keywords: Mucorales; ORBITAL exenteration; orbital apex syndrome; rhino-orbital mucormycosis; surgical debridement.

Figure 1

Clinical image of the patient (case 1) with confirmed rhino-orbital mucormycosis, demonstrating advanced involvement of the left periorbital region. There is marked swelling of both the upper and lower left eyelids, accompanied with significant ptosis that nearly obscures the palpebral fissure. Erythema and edema are evident, with distortion of normal periocular anatomy. The right eye remains relatively unaffected. The pronounced asymmetry and severity of left-sided changes are consistent with extensive local fungal invasion, characteristic of mucormycosis in immunocompromised individuals.

Figure 2

Clinical image (case 1) demonstrating the dorsum of the tongue with irregular, patchy areas of dark brown to black discoloration and surface coating. The lesion exhibits a heterogeneous texture with central pigmentation and surrounding erythematous mucosa, raising concern for possible fungal involvement or ischemic changes in the clinical context described.

Figure 3

Portable chest radiograph (PA view, supine) of the case 1, revealing bilateral diffuse interstitial infiltrates. The lung fields exhibit a reticulonodular pattern with increased interstitial markings, more prominent in the lower and mid zones, consistent with an interstitial process. Cardiac silhouette and mediastinal contours appear within normal limits. No gross pleural effusion or pneumothorax is identified.

Figure 4

Clinical image of case 2 diagnosed with rhino-orbital mucormycosis. The left eye demonstrates classic signs of orbital involvement, including marked periorbital edema, ptosis, conjunctival injection, and proptosis, in contrast to the unaffected right eye. Erythema and mottling over the nasal bridge and glabellar region suggest cutaneous extension and angioinvasive fungal infiltration. Subtle asymmetry in ocular alignment and lid positioning, more pronounced on the left, raises suspicion for early cranial nerve involvement particularly of the oculomotor and abducens nerves. These findings reflect the fulminant and rapidly progressive nature of mucormycosis.

Figure 5

Axial non-contrast CT scan of the orbits and paranasal sinuses of case 2 with rhino-orbital mucormycosis. The scan demonstrates opacification and mucosal thickening of the left ethmoid and maxillary sinuses, with soft tissue attenuation extending into the medial aspect of the left orbit (white arrow) through an area of bony erosion of the lamina papyracea (white star). Mild proptosis of the left globe is evident, along with obliteration of adjacent fat planes and stranding of the intraorbital fat, consistent with early orbital involvement. The right globe is unremarkable, maintaining normal position and contour. The sphenoid sinuses are partially aerated, with subtle mucosal thickening, suggesting early involvement without full opacification at this level.