Acute bilateral blindness in a young Covid-19 patient with rhino-orbito-cerebral mucormycosis
Journal of Ophthalmic Inflammation and Infection volume 11, Article number: 40 (2021)
A diabetic 20-year-old male patient, not previously vaccinated against SARS-CoV-2, was referred to our emergency department for rapid bilateral visual loss with left periorbital pain, proptosis, palpebral edema and swelling.
He had been admitted one week before in a primary Covid-19 center for COVID-19 respiratory distress syndrome and treated with corticosteroids.
Upon ophthalmic examination, both eyes had a fixed dilated pupil with no light perception. The left eye showed features of orbital cellulitis (Fig. 1) with complete ophthalmoplegia (Fig. 2). There was a mild proptosis and limited abduction in the right eye (Fig. 2), and fundus examination showed retinal whitening with a cherry red spot and segmental blood flow consistent with central retinal artery occlusion (CRAO) (Fig. 3). Swept source OCT showed in the right eye hyperreflectivity of inner retinal layers corresponding to ischemic edema (Fig. 3).
Brain CT complemented with cerebral MRI disclosed endocranial extension of the disease and thrombosis of both left cavernous sinus and left internal carotid artery (Fig. 1).
The patient underwent emergency endoscopic sinus examination and removal of a blackish necrotic tissues from paranasal sinuses. Histopathological examination confirmed the diagnosis of mucormycosis.
The patient was started on intra-venous liposomal amphotericin B and clavulanic-acid-amoxicillin. Dexamethasone was discontinued. Debridement of the involved sinuses and adjacent structures was attempted together with diluted amphotericin B irrigation. Orbital exenteration was discussed but it was not retained due to poor prognosis and lack of the patient’s consent.
Over the following days, the patient’s ocular and general conditions worsened due to bilateral extensive eyelid and facial necrosis with purulent melting of the left eyeball and central nervous system involvement (Fig. 4). He passed away at day 30.
With the onset of COVID-19 pandemic, clinicians have seen a sudden surge of cases of mucormycosis. Although all ocular structures may be involved in patients with COVID-19 infection, orbital mucormycosis seems to be the most aggressive and so far fatal complication [1,2,3].
To the best of our knowledge very few cases of severe bilateral blindness in Covid-19 patient have been reported [2,3,4,5,6]. They were related either to orbital location of mucormycosis [2, 3] or to neurological complications including bilateral optic neuritis  and occipital ischemic stroke [5, 6].
The presentation of our patient suggests a left cavernous sinus and internal carotid thrombosis together with a right CRAO. From the ophthalmic and other orbital arteries, fungal infection advanced into the left cavernous sinus, ipsilateral carotid artery and right central retinal artery. This resulted in acute onset of bilateral vision loss and left ophthalmoplegia.
Successful treatment of ROCM highly depends on the early diagnosis of the infection, the control of the underlying predisposing factors and aggressive surgery .
Hence, Ophthalmologists should have a high index of suspicion for mucormycosis development in diabetic patients with COVID-19 illness, treated with corticosteroids. Vaccination against SARS-COv2 seems to be the best treatment to prevent COVID-19 and related blinding and fatal diseases.
Availability of data and materials
For data, please refer to corresponding author.
Central Retinal Artery Occlusion
Sen, M., Honavar, S. G., Sharma, N., & Sachdev, M. S. (2021). COVID-19 and eye: a review of ophthalmic manifestations of COVID-19. Indian J Ophthalmol, 69(3), 488–509. https://doi.org/10.4103/ijo. IJO_297_21
Veisi, A., Bagheri, A., Eshaghi, M., Rikhtehgar, M. H., Rezaei Kanavi, M., & Farjad, R. (2021). Rhino-orbital mucormycosis during steroid therapy in COVID-19 patients: a case report. European journal of ophthalmology, 11206721211009450. Advance online publication. https://doi.org/10.1177/11206721211009450, 112067212110094
Eswaran, S., Balan, S. K., & Saravanam, P. K. (2021). Acute fulminant Mucormycosis triggered by Covid 19 infection in a young patient. Indian journal of otolaryngology and head and neck surgery : official publication of the Association of Otolaryngologists of India, 1–5. Advance online publication. https://doi.org/10.1007/s12070-021-02689-4
Mabrouki FZ, Sekhsoukh R, Aziouaz F, Mebrouk Y (2021) Acute blindness as a complication of severe acute respiratory syndrome Coronavirus-2. Cureus 13(8):e16857 https://doi.org/10.7759/cureus.16857
Cyr DG, Vicidomini CM, Siu NY, Elmann SE (2020) Severe bilateral vision loss in 2 patients with coronavirus disease 2019. J Neuroophthalmol 40(3):403–405 https://doi.org/10.1097/WNO.0000000000001039
Atum, M., & Demiryürek, B. E. (2021). Sudden bilateral vision loss in a COVID-19 patient: a case report. Indian J Ophthalmol, 69(8), 2227–2228. https://doi.org/10.4103/ijo. IJO_3706_20
Honavar S. G. (2021). Code Mucor: guidelines for the diagnosis, staging and Management of Rhino-Orbito-Cerebral Mucormycosis in the setting of COVID-19. Indian J Ophthalmol, 69(6), 1361–1365. https://doi.org/10.4103/ijo. IJO_1165_21
We did not receive any funding.
Ethics approval and consent to participate
This brief report has been performed in accordance with the ethical standards as laid down in 1964 by the declaration of Helsinki and its later amendments. Anonymous case reports are approved by the ethics committee of our institution as long as written consent is obtained from the patients.
Consent for publication
Consent was signed by the patient.
No conflict of interest.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Malek, I., Sayadi, J., Lahiani, R. et al. Acute bilateral blindness in a young Covid-19 patient with rhino-orbito-cerebral mucormycosis. J Ophthal Inflamm Infect 11, 40 (2021). https://doi.org/10.1186/s12348-021-00272-0