Acute Invasive Fungal Rhino Orbital Sinusitis: Imaging-Driven Stratification and Orbit-Sparing Therapeutic Paradigms

Acute invasive fungal rhino-orbital sinusitis (AIFROS) is a fulminant, angioinvasive infection that can rapidly threaten vision, the orbit, and life. Traditional management has often favored radical orbital exenteration once orbital or apical disease is detected, based on the assumption that removal of orbital tissue limits intracranial spread. However, growing clinical and radiologic evidence suggests that disease biology, particularly tissue perfusion and vascular dissemination, may be more important than the anatomic extent of orbital involvement alone. This manuscript presents an imaging-driven, biologically grounded framework for managing AIFROS with an emphasis on orbit preservation whenever feasible. Contrast-enhanced magnetic resonance imaging is proposed as the central tool for assessing tissue viability, distinguishing viable inflamed tissue from localized or diffuse necrosis, and identifying intracranial vascular spread. This stratification supports targeted treatment using systemic antifungals, aggressive sinus debridement, transcutaneous retrobulbar amphotericin B injections, and selective orbital debridement, rather than routine exenteration. Particular attention is given to the orbital apex, where involvement does not necessarily mandate radical surgery. Instead, cavernous sinus disease, internal carotid artery involvement, and cerebral infarction emerge as stronger predictors of mortality. Contemporary evidence increasingly supports orbit-sparing management in selected patients without compromising survival. AIFROS should therefore be approached as a perfusion-driven disease, where treatment is tailored to tissue vitality and vascular behavior rather than surgical radicality alone.