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to report a case of bilateral ophthalmic artery occlusion in rhino - orbito - cerebral mucormycosis .
an 89-year - old man with poorly controlled diabetes developed sudden bilateral ptosis , complete ophthalmoplegia of the right eye , and superior rectus palsy of the left eye .
brain and orbit magnetic resonance imaging showed midbrain infarction and mild diffuse sinusitis . on the 2nd day of hospitalization , sudden visual loss and light reflex loss developed .
there were retinal whitening , absence of retinal arterial filling , and a total lack of choroidal perfusion on fluorescein angiography of the right eye .
the left eye showed a cherry red spot in the retina and the absence of retinal arterial filling and partial choroidal perfusion on fluorescein angiography .
on rhinologic examination , mucormyosis was noticed . despite treatment , visual acuity and light reflex did not recover and he died 4 days after admission .
an 89-year - old man presented with sudden onset of bilateral ptosis on november 2 , 2005 .
three days prior to hospitalization , the patient was diagnosed with diabetes mellitus and had a history of surgery for gastric cancer , which occurred four years ago .
his fasting glucose level and postprandial ( 2 hr - after - meal ) glucose level were 196 mg / dl and 300 mg / dl , respectively .
complete ophthlamoplegia of the right eye and superior rectus palsy of the left eye were observed .
his anterior segment examination was notable for moderate nuclear sclerotic cataracts and mild chemosis , while fundoscopic examination revealed no specific abnormal finding .
brain and orbit magnetic resonance imaging ( mri ) revealed no specific abnormal findings in the cavernous sinus and orbit , except bilateral midbrain infarction and mild diffuse sinusitis ( fig .
the bilateral ptosis and superior rectus palsy of the left eye were regarded to be caused by 3 nuclear palsy .
the results of csf analysis showed that white blood cell count and protein were elevated and intravenous antibiotics were given for a central nervous system infection .
on november 3 , 2005 , the visual acuity of both eyes decreased to perception of hand motion and bilateral complete ophthlamoplegia developed ( fig .
fundoscopic examination revealed that the optic disc was pale and the posterior pole was generally edematous in both eyes .
fluorescein angiography ( fag ) demonstrated that retinal vessels were not imaged , even 10 minutes after injecting the dye .
choroidal perfusion was not found in the right eye and partial choroidal fluorescence was observed in the left eye ( fig .
thus , he was diagnosed with simultaneous bilateral ophthalmic artery occlusions . on the same day , rhinologic examination revealed a destructed nasal septum , black necrotic lump in the nasal cavity and an ulcer on the hard palate , which was confirmed as murcomycosis upon biopsy ( fig .
rocm was diagnosed and amphotericin b ( 50 mg / day ) was intravenously administered .
although extensive local excision was required , the patient and his guardian rejected to have surgery . on november 6 , 2005 , the patient died .
typical rocm initially involves general weakness , headache in the occipital area , fever and bloody rhinorrhea .
subsequently , facial and/or orbital cellulitis , ptosis , and ophthlamoplegia occur.1 in this case , 3 nuclear palsy , 4th , and 6th cranial nerve palsies of the right eye initially developed and subsequently , ophthalmolplegia of the left eye and bilateral ophthalmic artery occlusions followed .
ferry et al.2 reported 16 patients with rhino - orbito - cerebral mucormycosis . in their report , rhinologic symptoms were mostly common initial symptoms ( 11 cases ) , while ocular pain and facial cellulitis were observed in 6 and 5 cases , respectively .
this patient did not complain of rhinologic symptoms , although rhinologic examination revealed a black eschar in the nasal cavity .
absence of a cherry red spot in the retina and fag finding of the right eye are consistent with concomitant choroidal and retinal ischemia .
although a cherry red spot in the retina was present in the left eye , retinal arterial imaging was not found , and partial choroidal perfusion was observed .
the lack of sign of anterior segment ischemia can be explained by incomplete ophthalmic arterial occlusion .
also , the 3 cranial nerve palsy of the right eye may have been caused by orbital ischemia , infarction of the midbrain , or both . in this case , the brain mri revealed no specific abnormal findings in the cavernous sinus and orbit , except bilateral midbrain infarction .
it suggested that midbrain infarction caused the ophthalmoplegia ; however , ocular ischemia secondary to invasion of the orbital artery can not be excluded as the cause of ophthalmoplegia .
the mechanism of orbital ischemia is that the hyphae have a marked tendency to invade and thrombose arteries.3,4 in this case , the orbital apex was not involved according to radiologic examination .
a case of unilateral orbital infarction syndrome associated with rhino - orbito - cerebral mucormycosis has been reported in korea.5 when the eye is infected , the choroids usually exhibit the greatest number of organisms , the fungi having entered the globe via the ciliary arteries.3,4 as is the case with acute central retinal artery obstruction , retinal opacification is also present with acute ophthalmic artery obstruction . however , the latter it is usually more pronounced , both in the severity and the extent of the area involved .
the presence of a cherry red spot with an acute ophthalmic artery obstruction is variable . with an ophthalmic artery obstruction , the presence or absence of a cherry red spot
is probably determined by the degree of choroidal hypoperfusion , the rapidity of onset of vascular compromise , and the duration of the insult .
the most common causes of ophthalmic artery and/or central retinal artery occlusion are embolization from ulcerated plaques of the carotid artery and atherosclerotic occlusion of the internal carotid artery .
however , it is extremely rare for either one of these etiologies to cause bilateral visual loss .
brown et al.6 reported a case of acute simultaneous bilateral obstruction of central retinal and posterior choroidal circulations in atrial fibrillation and typhoid fever .
a case of virtually simultaneous bilateral ophthalmic artery occlusions was reported in a patient with acquired immunodeficiency syndrome and central nervous system lymphoma . in rocm
, visual loss usually has been attributed to ophthalmic artery and/or central retinal artery occlusions ; however , most previous reports covered unilateral or sequential ophthalmic artery and/or central retinal artery occlusions .
physicians should be alerted to rhino - orbito - cerebral mucormycosis in patients who present with ocular abnormalities , including orbital cellulitis , ptosis , and ophthlamoplegia , and have diabetes mellitus or a weak immune system .
a high index of suspicion is very important for the early diagnosis of this very progressive disease .
our case illustrates that patients with rhino - orbito - cerebral mucormycosis can have bilateral ophthalmic artery occlusion and loss of vision within a few days .
purposeto report a case of bilateral ophthalmic artery occlusion in rhino - orbito - cerebral mucormycosis.methodsreviewed clinical charts , photographs , and fluorescein angiography.resultsan 89-year - old man with poorly controlled diabetes developed sudden bilateral ptosis , complete ophthalmoplegia of the right eye , and superior rectus palsy of the left eye . brain and orbit magnetic resonance imaging showed midbrain infarction and mild diffuse sinusitis . on the 2nd day of hospitalization , sudden visual loss and light reflex loss developed . 
 there were retinal whitening , absence of retinal arterial filling , and a total lack of choroidal perfusion on fluorescein angiography of the right eye . 
 the left eye showed a cherry red spot in the retina and the absence of retinal arterial filling and partial choroidal perfusion on fluorescein angiography . 
 on rhinologic examination , mucormyosis was noticed . despite treatment , visual acuity and light reflex 
 did not recover and he died 4 days after admission.conclusionsbilateral ophthalmic artery occlusion can occur in rhino - orbital - cerebral mucormycosis .