Transcaruncular medial orbitotomy: A globe sparing intervention in management of COVID associated mucormycosis [CAM]

To describe a novel method of transcaruncular medial orbitotomy, local debridement and amphotericin B irrigation into orbit for COVID-19-associated rhino-orbital mucormycosis. Also to evaluate its its outcome in controlling the disease, increasing the survival rate and as a globe-sparing intervention in them.

A total of ten COVID-19-associated mucormycosis patients with clinical and radiological evidence of orbital involvement with necrotic tissue localized in medial orbit were considered for our study. A transcaruncular modified medial orbitotomy with medial and inferomedial orbit debridement was done along with placement of scalp vein catheter by a single surgeon. Postoperatively 3.5 mg/ml liposomal amphotericin B irrigation through the catheter was done for 5 sittings. Correction of underlying systemic conditions and intravenous antifungals were given. Clinical response to the procedure was noted on postoperative week 1, week 4, and 3^rd month (week 12).

The mean age group was noted to be 49.9 years with a male: female ratio of 2.3:1. All patients were diabetics with 5 being newly detected diabetes after COVID infection. All the ten patients showed significant clinical improvement at the first follow-up (week 1). Five patients at 1^st month showed clinical and radiological improvement, while one patient had worsening of orbital disease for which exenteration was done. Three patients succumbed to the disease due to altered cardiopulmonary status and 1 patient was lost to follow-up. All 6 survived patients were stable till the last follow-up. Hence, mortality rate accounted to 30% and globe survival of 40% in the current study.

Transcaruncular approach to orbit for adequate debridement combined with amphotericin irrigation is a novel technique that can be considered for compartmental involvement of orbit in mucormycosis. Debridement removes the necrotic tissue, while local amphotericin irrigation directly reaches the target tissues that effectively halts the disease progression and hence can be considered an effective globe-sparing intervention without affecting the disease outcome.