Loss of vision secondary to a sphenoid fungal ball with full post-surgical recovery

An older adolescent immunocompetent male with a 2 month history of progressive frontal headaches, congestion and worsening vision, culminating in right optic neuropathy, was referred to our emergency department by ophthalmology. MRI revealed extensive sinus disease, though without direct optic nerve compression; CT scan identified a fungal ball extending into the right clinoid process, with bony erosion and involvement of the deep pneumatised optico-carotid recess. The patient underwent emergency endoscopic sinus surgery, where mucopus, polyps and fungal debris consistent with an infected fungal ball were found in the right nasal cavity and sphenoid sinus. Residual fungal material remained in the deep optico-carotid recess post-washout due to difficult access and dehiscent bony coverings of the optic nerve and carotid. Postoperatively, he was treated with voriconazole and intravenous co-amoxiclav. His vision returned to baseline 3 days postoperative and 3 months later, a second-look surgery confirmed no residual fungal material. Now fully recovered and discharged from follow-up.