A blind eye, saved. How aggressive local control let one orbit escape exenteration in fulminant rhino-orbito-cerebral mucormycosis.
A 17-year-old girl.Uncontrolled diabetes, a blackening cheek, three days.By the ICU, the eye had no light left to give.
A dusky discolouration over the right cheek and lid, treated first as preseptal cellulitis, the classic and costly early misstep. Within days vision collapsed from 6/18 to no light perception, with proptosis, chemosis and a frozen globe.
Angioinvasion is the hallmark. Broad, aseptate hyphae penetrate vessel walls, thrombose them, and infarct the tissue downstream. The black eschar is not surface debris; it is dead tissue mapping the vessels the fungus has already taken.
Mucoral spores are inhaled constantly and cleared harmlessly by most hosts. Diabetic ketoacidosis is uniquely permissive, and the reason is now molecular, not merely "impaired immunity."
CT of the paranasal sinuses and orbit (Fig 3) showed maxillary sinusitis breaching the inferior orbital wall. Histopathology (Fig 4) was diagnostic: broad, aseptate, wide-angle branching hyphae, the morphology of Mucor.
On the Honavar Code Mucor scale (nasal → sinus → orbit → brain), the disease had reached stage 4c: central nervous system extension, the far end of the Code Mucor scale and the point of highest mortality. In the largest Indian series, exenteration lowered mortality at this stage, which makes a globe-preserving survival here uncommon.4,9
Aggressive endoscopic sinus and midface debridement to secure local control, with the globe deliberately preserved and the cheek defect covered by a local flap.
Medical therapy followed the guideline spine: amphotericin B with tight glycaemic and metabolic control, escalated to salvage triazoles (posaconazole / isavuconazole) when the early response fell short. ECMM strongly recommends high-dose liposomal amphotericin B (≥5 mg/kg) with early surgery and reversal of the metabolic derangement.10,11
Blind and shrunken, now managed with a cosmetic shell. Not vision, but life, and an intact socket, spared the psychological and reconstructive morbidity of exenteration.
In a young patient with a reversible risk factor and disease that responded to therapy, the globe was preserved even as the infection reached the brain, a rare outcome where exenteration is often the default.
A black necrotic lesion in a diabetic is an angioinvasive mould until proven otherwise. Antibiotics for "preseptal cellulitis" buy the fungus time.
Uncontrolled diabetes and corticosteroid exposure, here from an unqualified practitioner, are the key and largely preventable risk factors.
The cornerstones are early high-dose liposomal amphotericin B, aggressive surgical debridement, and reversal of the ketoacidosis, not any one of them alone.
Exenteration is not always mandatory: here the globe was preserved even with intracranial disease, though honestly not vision, an uncommon outcome that argues for individualised decisions.
This is a single case. It is hypothesis-generating and educational; it cannot establish cause and effect, and its outcome may not generalise.
The evidence favouring globe preservation is observational and prone to selection bias, since more severe eyes are exenterated. It shows exenteration has not been proven to improve survival, which is not the same as showing it worsens survival.
Staging rested on CT. Contrast-enhanced MRI is more sensitive for orbital apex, perineural and cavernous-sinus or intracranial spread, and would have strengthened the assessment.
Follow-up is limited. Recurrence remains possible, and longer surveillance is needed before calling this a durable cure.
Written informed consent for publication of the case and clinical images was obtained from the patient and her legal guardian (a minor).
Identifying facial features are redacted and every clinical image sits behind a deliberate reveal, applied alongside consent, not instead of it.
Prepared in keeping with the ICMR National Ethical Guidelines (2017) for the reporting of clinical case material and for informed consent.
Authorship meets ICMJE criteria and all authors approved the final version. All clinical details and images pertain to the index patient, with no fabrication.
The family's documented priority throughout was to avoid losing the eye; the globe-preserving plan aligned with that wish and defensible clinical grounds.
No conflicts of interest are declared and no funding was received.
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