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Danielle Trief, Stacey T Gray, Nipun Chhabra, Michael K Yoon; Outcomes of Invasive Fungal Disease. Invest. Ophthalmol. Vis. Sci. 2014;55(13):4084.
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Invasive fungal orbital infections are severe, life threatening events with a high morbidity and mortality. To better understand this rare disorder, we reviewed the care of patients treated at our institution.
The records of patients treated at Massachusetts Eye and Ear Infirmary (MEEI) or Massachusetts General Hospital (MGH) between January 1994 and December 2012 for invasive fungal orbital infection were retrospectively reviewed.
In total, 12 patients met inclusion criteria. There were 4 women and 8 men with a mean age of 55 years (range 34 - 80). There were 4 patients with uncontrolled diabetes, 6 patients with diabetes and systemic immunosuppression, and 2 patients with immunosuppression alone. Presenting signs included vision loss, ophthalmoplegia, blepharoptosis, proptosis and pain. 6 patients had a presenting vision of NLP or worse in at least one eye, and 10 had vision that was 20/400 or worse. 5 patients had a central retinal artery occlusion (CRAO) and all patients had cranial neuropathies. 73% of patients, in which hertels were checked, had proptosis on initial exam. Fungal speciation showed 10 patients with mucormycosis, 1 with mixed fungi (aspergillus and mucor), and one with an atypical, unspeciated fungus. Many patients were initially diagnosed with another orbital process: orbital bacterial cellulitis, orbital pseudotumor, or lymphoma. Four patients were initially improperly treated with IV steroids. Patients were treated with a combination of surgery and IV antifungal medication. Nine patients died as a result of their infection (75% mortality). In patients with mucor infection alone, the average time from symptom onset to death was 24.4 days (range 5-50 days), while the average time to diagnosis was 10.1 days (range 2-30 days). All three of the surviving patients had diabetes and none had a transplant. Conversely, all four transplant patients passed away.
Although this is the largest single institution review to date, over the past twenty years, invasive fungal orbital infection has continued to have a high rate of mortality. In our institution, there was a high proportion of patients who had undergone transplant requiring chronic immunosuppression. Diabetes alone as an immunocompromising factor was seen in only 25% of patients. Clinicians should have a high suspicion for orbital fungal disease when vision loss is accompanied by cranial neuropathies, pain, proptosis or CRAO in immunosuppressed patients.
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