The ROC Staging System for COVID-related Rhino-Orbital-Cerebral Mucormycosis.

Purpose: To report and validate an objective staging system for COVID-related Rhino-Orbito-Cerebral mucormycosis (ROCM).Methods: Proof of concept of a new ROC staging system was devised for COVID-related ROCM. The staging system was based on data points drawn from a comprehensive ophthalmic examination, diagnostic endoscopy, and appropriate imaging of orbit, paranasal sinuses and brain in post-COVID ROCM patients to formulate the final staging expressed as R0-3O0-3C0-3. Each stage in the sinus, orbit and brain was graded into three levels of severity of disease. Progressive stages necessitated more active and urgent intervention and poorer prognosis. Finally, ten consecutive ROCM patients were independently staged by two blinded clinicians by examining clinical photographs and radiological images and the results matched for concordance.Results: Each component of the staging: Rhino, Orbital, and Cerebral were graded 0-3 based on severity. Each stage was matched with a recommended management plan. The final ROC grading by two independent clinicians showed a high degree of concordance - maximum for orbit grade (100%) followed by brain (90%) and sinuses (80%). Overall R0-3O0-3C0-3 staging had 70% concordance. Extrapolation of final ROC staging of two clinicians showed 60% match. When we allowed for one-point difference in the ROC staging system the concordance between two clinicians improved to 100% and the management plan matched in 90%.Conclusion: The proposed ROC staging system based on objectively defined clinico-radiological criteria of the three components of COVID-related ROCM is simple-to-use and has high concordance when validated by independent clinicians. The staging helps devise a management plan and has prognostic value.