• Oculoplastics/Orbit

    Review of: Outcomes of a modified treatment ladder algorithm using retrobulbar amphotericin B for invasive fungal rhino-orbital sinusitis

    Ashraf D, Idowu O, Hirabayashi K, et al. American Journal of Ophthalmology, May 2022

    As transcutaneous retrobulbar amphotericin B (TRAMB) injection has been used for routine care only since 2015, this retrospective, controlled study compared outcomes in patients with invasive fungal rhino-orbital sinusitis treated before and after 2015.

    Study design

    Investigators studied data from 50 consecutive patients with proven invasive fungal sinusitis with orbital involvement seen at a single US center between 1999 and 2020. The outcomes of a modified treatment ladder algorithm using TRAMB injection for moderate orbital disease were compared with those of historical control subjects (seen before 2015). The treatment algorithm escalated treatment invasiveness based on disease severity. TRAMB was performed with 1 mL of a 3.5 mg/mL concentration of liposomal amphotericin B, and magnetic resonance imaging was used to determine the extent of devascularized tissue based on loss of contrast enhancement.

    Outcomes

    Thirty of 50 patients (33 of 55 affected eyes) received the modified algorithm of TRAMB. Baseline demographic and clinical characteristics were similar between the patient populations. Prior to 2015, 36.5% of patients were exenterated, compared with 9.1% after 2015. Final visual acuity was better in the post-2015 group, and fewer patients had worse vision at the final follow-up visit (12.5% vs 50.0% of the pre-2015 group). Overall, TRAMB was safe, with a 4.3% complication rate due to orbital inflammation or hemorrhage, and mortality rates were similar in the pre- and post-2015 groups.

    Limitations

    The study size was relatively small, with a heterogenous population. It is possible that medical treatment, in general, was better for more recent patients than for those treated before 2015, which could have affected the results. It would be ideal to conduct a prospective, randomized, case-controlled study to confirm this study’s results.

    Clinical significance

    This study supports the treatment of invasive fungal sinusitis with retrobulbar amphotericin B injections, rather than the traditional treatment with exenteration for select cases. The adaption of TRAMB appears to decrease the need for exenteration; however, mortality is not affected.