Year : 1983 | Volume
: 31 | Issue : 4 | Page : 425--427
SP Dhir, VP Munjal, Amod Gupta, IS Jain
Department of Ophthalmology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
S P Dhir
Department of Ophthalmology, Postgraduate Institute of Medical Education & Research, Chandigarh-160012
|How to cite this article:|
Dhir S P, Munjal V P, Gupta A, Jain I S. Rhino-orbito-cerebral, mucormycosis.Indian J Ophthalmol 1983;31:425-427
|How to cite this URL:|
Dhir S P, Munjal V P, Gupta A, Jain I S. Rhino-orbito-cerebral, mucormycosis. Indian J Ophthalmol [serial online] 1983 [cited 2021 Jan 15 ];31:425-427
Available from: https://www.ijo.in/text.asp?1983/31/4/425/27571
The classical syndrome of uncontrolled diabetes, nasal sinusitis, orbital cellulitis, ophthalmoplegia and moningoencephlitis caused by mucormycosis was first described by Gregory et al in 1943. This condition develops as a result of infection by a saprophytic fungus belonging to family mucoraceae. This fungus becomes pathogenic when the suitable conditions exist like diabetes mellitus with acidosis. Few other conditions like leukemia, multiple myeloma, oliguric renal failure, severe diarrhoea and patients on intensive chemo therapy are also reported to be associated with this condition. The literature on this subject is mainly based on case reports and no clear cut ophthalmic features of this disease are described. The present endeavour is to put on record our observations on three cases of mucormycosis and high light certain ocular features of this disease. The brief summary of the cases is as follow:
Case No. I :- D.P., a 28 years old man was seen by us on Oct. 27, 1979. His present complaints started two months back when he developed diffuse swelling over the right half of this face followed by diminution of vision and drooping of the lid of the right eye. Subsequently he started having blood tinged nasal discharge and developed nasal twang in his voice. He was detected to be diabetic and was taking oral hypoglycemic very irregularly. The examination by us on that day revealed; depressed bridge of the nose with a healed sinus, another sinus over the medial canthus discharging yellowish necrotic material. Anterior rhinoscopy revealed atrophic turbinales which were black and gangrenous. There was a perforation in the hard palate. Ocular examination revealed; right eye ball was proptosed, there was ptosis with swelling of the lids [Figure 1][Figure 2]. The patient was not perceiving light in this eye. Anterior segment was unremarkable except non reacting pupil. Lens was clear. In the anterior vitreous there was yellowish, fluffy mass seen floating. The eye ball was soft and fundus glow was not visible. The left eye was unremarkable except hypermetropia of 5 diopters. In addition there was paralysis of 111, IV, V, VI and VIII nerves on the right side and supranuclear paralysis of VII nerve on the left side. The significant positive laboratory investigations were: ESR 50 mm Ist hr, Blood sugar levels varied from 250 mg ° %, to 392 mg%, microscopic examination of the pus from the sinus showed broad, nonseptate, occasionally branching hyphae. Biopsy from the edge of the palatal perforation revealed non-septate hyphae. It was observed while performing biopsy that there was hardly any bleeding from the wound. He was put on insulin to control his diabetes and treatment with amphotericin was planned.
Case No. 2 :- H.S. 42 years old man attended ENT clinic of our Hospital on 17.9.77. His present illness started 2 weeks back when he developed, pain and swelling around the left ear. He was running high grade fever for the same duration. He was drowsy and multiple cranial nerve were involved; V, VI, IX and Xnerves on both side and in addition VII and XII on the left side. Ocular examination on this day revealed; moderate axial proptosis of the left eye ball with chemosis of the conjunctiva in the lower quadrant. Corneal reflexes were diminished on both sides, pupils were well reacting and fundi were normal.
Except for ESR of 50 mm, all other laboratory investigation were negative. He was running a down hill course inspite of the intensive antibiotic therapy. On the 6th day of admission he lost vision from his left eye which was attributed to central retinal artery occlusion in that eye. The proptosis and chemosis increased and few snow-ball opacities were seen in the vitreous two dayslater. All the para-nasal sinuses were explored by the ENT surgeon. The mucous membrane of the sinuses was oedematous, and thickened. The floor of the orbit was also explored which was found to contain black nectrotic material. This material failed to show fungus on microscopic examination, nor the culture grew any fungus. The left eye ball became shrunken and chemosis further increased. The orbit was exentrated under local anaesthesia. It was observed there was very little bleeding at the time of surgery. The orbit was filled with black necrotic material which was extending into the cranium through the superior orbital fissure. The bones were not eroded. The eye ball was shrunken but intact. The smear from
this material showed non-septate hyphae. He was treated with intra-venous amphotericinB, but the patient died two weeks later.
Case No. 3 :- Forty years old female, who was diabetic and was on irregular treatment with oral hypoglycemics. She was seen by us on 6. 11.80. Her present illness started 15 days back when she developed pain and redness in both the eyes. Eight days back she developed protrusion of the right eye ball, drooping of the upper lid and loss of vision. These symptoms were preceeded by fever for one day. On examination she was found to have no perception of light in the right eye. Rignt eye ball was proptosed with severe ptosis [Figure 4]. There was total ophthalmoplegia. Retro-ocular resistance was increased. Fundus showed pale oedema of the disc and arterioles were narrow, suggestive of central retinal artery occlusion. Left eye was essentially normal. Laboratory investigations revealed ; total leucocytic count 8300/cm with predominance of polymorphonuclear cells. ESR 92 mm Ist hr., fasting blood sugar 295 mg% and post parandial 408 mg%. She was treated with antidiabetic regimen and systemic steroids with no effect on the ocular condition. Anterior orbitotomy was done, which revealed yellowish necrotic tissue in the central space. It was observed that the there was very little bleeding during operation. The material obtained showed broad non-septate hyphae in the fibro-fatty tissue [Figure 5]. She was treated with I/V amphotericin-B. Her eye condition is stationary and she had not demonstrated any signs of cerebral involvement.
Central retinal artery occlusion is invariably the cause of sudden loss of vision in mucormycosis. It has been observed by Abramson that early visual loss and evidence of central retinal artery occlusion in a case of cavernous sinus thrombosis is an important sign of orbital mucormycosis and is of value to differentiate this condition from pyogenic cavernous sinus thrombosis. This observation was found true in two of our cases (case No. 2, 3). The appearance of fluffy masses in the vitreous and hypotony following central retinal antery occlusion (case No. 2) suggests ischaemia of the eye ball which may be the result of thrombosis of posterior cilliary arteries. Similar fluffy masses were seen in case No.1 which is presumed to be the result of similar pathology. Ocular manifestations of mucormycosis have been summed up by Gass in a review of 28 cases from the literature. The clinical diagnosis in a case with the clinical signs of involvement of nose, orbit and intracranial structures is not a problem. The problem arises in cases where the course is chronic with only ocular involvement like in case No. 3. The development of central retinal artery occlusion and the fluffy masses in the vitreous has provided an important clue to the diagnosis of mucormycosis in this case.
Another observation, which may be of practical importance is that, these cases bleed very little during surgery. This phenomenon was observed in all these three cases. This observation has also been made by Coetzee while doing antrostomy in his reported case.
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