Retrobulbar Injection of Amphotericin B for Orbital Mucormycosis

Abstract

A 68-year-old immunocompromised man with rhino-orbital-cerebral mucormycosis was treated with retrobulbar injections of amphotericin B deoxycholate in conjunction with intravenous antifungals and endoscopic sinus debridement. Transient episodes of orbital inflammation were noted after retrobulbar injections, but progression of orbital infection was halted and visual acuity restored with eventual hospital discharge. To the authors' knowledge, clearance of orbital mucormycosis with retrobulbar amphotericin B injections has not been previously reported. This intervention may be a viable therapeutic option in cases of orbital mucormycosis where aggressive orbital debridement is not favored and/or the burden of orbital disease is not substantial. However, physicians should be aware of the risk of transient orbital inflammation secondary to retrobulbar amphotericin B deoxycholate.

Outcomes of a Modified Treatment Ladder Algorithm Using Retrobulbar Amphotericin B for Invasive Fungal Rhino-Orbital Sinusitis

“…In one case, an orbital compartment syndrome developed and required emergent lateral canthotomy and cantholysis 22 ; in the other, intraocular pressure was normal and the inflammation was managed expectantly. 23 In both cases, there was full recovery from the episode of orbital inflammation with final visual acuity of 20/20. The third complication was a retrobulbar hemorrhage that developed after the second injection in a patient with platelet count of 27,000 cell/L.…”

“…The authors also previously reported anecdotal evidence among two patients in whom marked improvement was noted after an initial series of TRAMB, followed by decompensation days to weeks later, and then rapid, sustained improvement with a second series of TRAMB. 22,23 The third interpretation is that confounding factors may explain these findings. Though consecutive patients of one institution were compared, there were some differences in the initial demographic and clinical characteristics.…”

“…Other groups have reported bedside transcutaneous retrobulbar injection of amphotericin B (TRAMB) as a minimally invasive alternative to surgical treatment with favorable outcomes in a small number of reports. 8,[21][22][23][24][25][26] The authors began offering this modality at their institution as part of a modified treatment ladder algorithm, and herein present their clinical results for patients treated with this algorithm.…”

Etiologies of proptosis: a review

“…Frozen sections or specimens stained with calcofluor help assess margins. 16,17 Globe sparing treatments have been described in case reports, showing success with intraorbital amphotericin injections, however, not all cases are amenable to this approach and this modality should be approached with caution given the high mortality associated with this disease process.…”

Orbital mycoses in an adult subtropical population

“…Other measures such as daily irrigation and packing of the involved orbit and sinuses with AMB have been reported to increase drug delivery directly to the infected tissues with improved chances of recovery from mucormycosis [ 2 , 24 ]. Hirabayashi et al recently reported a novel case of successfully treated orbital mucormycosis with retrobulbar injection of AMB without exenteration [ 25 ]. Intraorbital injection of AMB has also been shown to be effective palliative therapy in patients unable to undergo aggressive surgical debridement [ 26 ].…”