key: cord-0700854-1eun3haj
authors: Murthy, Ramesh; Bagchi, Aadhyaa; Gote, Yogita S
title: Role of medial orbital wall decompression in COVID-19-associated rhino-orbital mucormycosis management
date: 2021-12-03
journal: Indian J Ophthalmol
DOI: 10.4103/ijo.ijo_1294_21
sha: cc42e9d3390cc21296a593a1d5b3a5cebe067138
doc_id: 700854
cord_uid: 1eun3haj

nan

In our series of 111 cases of rhino-orbital mucormycosis, we performed an MRI scan or CT scan in all patients. All the patients were receiving intravenous liposomal amphotericin B, which is fungicidal. All cases underwent functional endoscopic sinus surgery (FESS) and at the time of completion of FESS, the nasal cavity and sinuses were thoroughly debrided and washed. When we noted signs of orbital inflammation or raised intra-orbital pressure, as judged by finger pressure comparing the two eyes or if there were clinical signs such as chemosis, ptosis, ocular movement limitation, or diminution of vision, we performed an endoscopic removal of the ethmoid bone completely, thus exposing the periorbita and made two cuts in the periorbita, above and below the medial rectus muscle anteroposteriorly and allowed orbital fat to prolapse into the sinuses. Thirty-six patients underwent this medial orbital wall decompression, and none needed orbital exenteration. Postoperatively, there was an improvement of the ptosis, and ocular movements, resolution of the chemosis, and vision was maintained or improved in all patients [ Fig. 1 ]. Five patients had no light perception at presentation and vision did not improve in them. There was no recurrence at the 3-month follow-up. MRI scan shows enlarged extraocular muscles in most cases with pressure on the optic nerve and this surgical maneuver relieves this pressure. This surgical step is commonly performed in cases of thyroid eye disease where there are signs of inflammation and increased intra-orbital pressure. [1, 2] We recommend performing this surgical procedure along with FESS as needed, as this is effective in preventing unsightly proptosis with loss of vision and thus obviates the need for exenteration.

Dear Editor, Since the COVID-19 pandemic started, numerous guidelines have been released to protect health care workers (HCWs), who are at a threefold higher infection risk. [1] Recognizing conjunctival infection routes, protective goggles, and face shields have been recommended in personal protective equipment (PPE). [2] However, invariable fogging-up of protective eyewear due to perspiration and exhaled humid air causes an early, sharp reduction in visual acuity, significantly limiting functionality. It also makes HCWs prone to physical injuries. Cleaning this moisture is impossible without PPE-breach.

Methods like taping the mask's upper edge, making holes on the goggle's sides, and placing eyewear in warm water help little. [3] Liquid soap, iodophor, hand sanitizer, [4] commercial anti-fogging agents, [3] and anti-fogging films have been individually reported to be variably effective, with fog-free time, when mentioned, ranging from 1 to 8 hours, and usually tested up to 2 hours. [5] Cleansing agents and sanitizers have been hypothesized to work by lowering the surface tension, which causes water molecules to spread out evenly into a transparent layer. [6] The study followed the tenets of the Declaration of Helsinki. Ten HCWs in COVID-19 intensive-care units used five anti-fogging methods for polycarbonate-based protective goggles. The agents were applied evenly on both surfaces of the goggles using a gauze piece followed by air drying. Methods used were as follows. A: Application of a liquid mixture of propan-1-ol and propan-2-ol (75%) (Sterillium TM ); B: Sodium lauryl-ether sulfate + sodium chloride solution (Baktolin 5.5 TM ), a nonsoap handwash lotion containing surfactants; C: Spray-application of dimethyl carbinol + isopropyl alcohol (Colin TM ), a household surface cleaning agent. D: Sterillium TM followed by Baktolin 5.5 TM . E: A novel 3-agent sequence of Sterillium TM , Baktolin 5.5 TM , and Colin TM . These methods required <5 minutes for application. All HCWs had normal visual acuity (0 LogMAR, Snellen 6/6) after donning PPE; 50% used spectacles. Time taken for reduction in distance visual acuity to 1 LogMAR (Snellen 6/60) was named "complete fogging time" [ Table 1 ]. A control group of 10 residents was taken without application of any anti-fogging agents. All groups (including controls) taped exposed edges of their masks and the eyewear using similar ways to ensure airtightness and reduced exposure to COVID-19 infection. Fogging time was compared using related samples Friedman's ANOVA test with a Bonferroni correction using SPSS software version 26 (IBM, NY, USA). P < 0.05 was considered significant. Methods B, D, and E were significantly better than controls and methods A and C (P < 0.05). No cutaneous or ocular irritation was reported.

The 3-agent combination showed a consistent fog-free effect for up to 6 hours of active work [ Fig. 1 ]. We could not 

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