A Study on the Impact of Diabetes Mellitus on the Severity of COVID-19-Associated Mucormycosis

Objectives: Diabetes mellitus (DM) seems the most common predisposing factor for rhino-orbito-cerebral mucormycosis (ROCM). This study aimed to study the impact of DM on the severity of COVID-19-associated ROCM (CAM). Methods:?This was a retrospective analytical study performed over a period of 3 months to assess the impact of DM on the severity of CAM in 100 patients and association of clinical correlates of DM with severity of CAM. Statistical analysis:?The data collected using the study tools were converted into a computer-based spreadsheet and analyzed. The statistical analysis comprised a descriptive analysis that involved calculating means, standard deviations, and proportions. For calculating the significance of the difference of mean between two groups, Student's t-test was applied. In addition, chi-square test (or Fisher's t-test if applicable) was applied to study the significance of association of clinical correlates of DM with severity of CAM for categorical variables and t-test for continuous variables. Results:?The prevalence of DM was 67%. The average presenting blood sugar level was 245.9?±?99.86?mg%. Glycated hemoglobin level between 4.5 and 6.5% was observed in 57 patients and over 6.5% in 43 subjects. A high body mass index (BMI) of 25 and above was noted in 52 patients. A significantly higher level of presenting blood sugar and a longer duration of hospital stay was noted in patients having stage 3b or higher (p?<?0.05) when compared with those having stage 3a or below. No significant correlation was observed in patients in stage 3a or below and those presenting with stage 3b or higher in terms of BMI, waist to hip ratio, or total cholesterol levels. There was a strong correlation between blood sugar level at presentation, severity of DM with the severity of ROCM, and a strong inverse correlation noted between HDL level and severity of ROCM. Conclusion:?A poor metabolic control is associated with a higher risk of a severe disease with intracranial involvement.

Corneal manifestations and treatment among patients with COVID-19-associated rhino-orbito-cerebral mucormycosis

Purpose: TO report the corneal manifestations in patients with COVID?19?associated rhino?orbito?cerebral mucormycosis (ROCM). Methods: This study was a retrospective, observational, and record?based analysis of patients of ROCM with corneal involvement. Results: A total of 220 patients were diagnosed with ROCM over a period of 3 months. Thirty?two patients had developed corneal manifestations. The mean age at diagnosis was 52.84 ± 12.8 years. The associated risk factors were systemic mucormycosis, uncontrolled diabetes, recent COVID?19 infection, and injudicious use of systemic steroids. Twenty?nine patients were known diabetics, 32 had recent COVID?19 infection, and 13 gave a history of injudicious use of steroids. The right eye (RE) was affected in nine patients, the left eye (LE) in 20 patients, and both eyes in three patients. Nine patients had a round?oval corneal ulcer. One patient each had a perforated corneal ulcer with uveal prolapse, sealed perforated corneal ulcer, spontaneously healed limbal perforation, diffuse corneal haze with hyphemia, panophthalmitis, diffuse corneal stromal abscess, limbal ischemia, anterior uveitis with posterior synechiae, inferior corneal facet, and filamentary keratitis. Three patients each had a corneal melt and inferior conjunctival xerosis with chemosis. Orbital exenteration was performed in six patients. Five patients with corneal ulcers healed. Topical eye drops of amphotericin (0.5 mg/ ml) cycloplegic, antiglaucoma medications, and lubricant eye drops were started along with systemic antifungals. Conclusion: Central corneal ulcer was the most common manifestation of mucormycosis. A concentration as low as 0.5 mg/ml of amphotericin eye drops was effective in the treatment.

Comparative evaluation of outcomes of novel approach of subconjunctival Mitomycin C (MMC) injection at the end of trabeculectomy versus intraTenon injection of MMC prior to the initial conjunctival incision – A pilot study

Purpose: To describe a novel approach of subconjunctival injection of mitomycin C (MMC) at the end of trabeculectomy and compare it with intraTenon MMC injection. Methods: This pilot study included 40 eyes of 40 patients with uncontrolled primary and secondary glaucoma. Patients below18 years and failed trabeculectomy were excluded. Patients were randomly allocated into groups A and B (20 patients each). Group A patients received subconjunctival MMC injection in the superonasal quadrant at the end of standard trabeculectomy. Group B received an intraTenon MMC injection before the initial conjunctival incision. Outcome measures included intra?ocular pressure (IOP) reduction, bleb morphology, and complication rates. The complete success was defined as an IOP of ?21 mmHg without antiglaucoma drugs. Results: The mean preoperative IOP of 46.00 ± 11.2 mmHg in group A and 43.05 ± 10.3 mmHg in group B reduced to 12.00 ± 2.41 mmHg (P ? 0.001) in group A and 13.65 ± 2.76 mmHg in group B (P ? 0.001) at last follow?up. Complete success was 95% and 75% in groups A and B, respectively, 19 months after surgery. Avascular microcystic blebs (70% of group A and 45% of group B) were more common than avascular white blebs (15% in group A and 35% in group B). No intraoperative complications were seen. Postoperative wound leak, hypotony, choroidal detachment, or endophthalmitis were not encountered in any group. Conclusion: A novel approach of subconjunctival MMC application during trabeculectomy is reported. Both approaches appear to be highly effective in reducing IOP in primary and secondary glaucoma with similar safety profiles and bleb morphology. Subconjunctival MMC yielded a greater success rate (95%) compared to the intraTenon MMC group (75%)

Demographic and Clinical Profile of Patients Presenting with COVID-19-Associated Rhino-orbito-cerebral Mucormycosis at a Tertiary Care Center

Objectives?Individuals affected with rhino-orbito-cerebral mucormycosis (ROCM) associated with coronavirus disease 2019 (COVID-19) increased enormously in northern India during the second wave of the novel coronavirus disease. This study determined the demographic and clinical profile including the risk factors in patients presenting to a tertiary care hospital in northern India. Materials and Methods?This is a descriptive study involving patients admitted with COVID-19-associated ROCM and were managed from May 2021 to 20th July 2021. Statistical Analysis?The data was analyzed using SPSS (IBM SPSS Statistics 20, SPSS Inc., Chicago, Illinois, United States) software and Microsoft Excel (Version 16.49). The chi-squared and Fisher's exact tests were used to compare various outcomes. A p-value of less than or equal to 0.05 was considered to be statistically significant. Results?One hundred and seventeen (117) patients (males: 70 [59.8%], females:47 [40.2%]) with the average age of 51.85?±?12.80 years presented with orbital involvement. Diabetes mellitus was noted in 100 (86.2%) patients. Of the available data from the records, oxygen supplementation for the management of COVID-19 was received by 37/108 (34.3%) patients for a median average duration of 11 days. Forty-eight patients of one-hundred-seventeen (60%) patients were treated with corticosteroids with a median duration of steroid administration being 10 days. The duration between onset of symptoms related to mucormycosis and diagnosis of COVID-19 was 0 to 75 days for 48 patients. Intravenous amphotericin B was administered in all cases. External sinonasal debridement was performed in 90 of 114 (78.9%) patients, retrobulbar amphotericin B injection was administered in 56 of 117 (47.9%), and orbital exenteration was performed in 17 of 117 (14.5%) of cases. Conclusion?Administration of corticosteroids and diabetes mellitus seem to be the major underlying causes for the development of COVID-19-associated ROCM. Prompt diagnosis and multidisciplinary management approach are essential for a reduction in mortality.

Burden and depression in primary caregivers of persons with visual impairment.

Context: Caregivers who assist persons with visual impairment often neglect their needs, resulting in burden and depression. Rehabilitation efforts, directed to the disabled, seldom target the caregiver. Aim: To assess burden and depression in persons caring for blind individuals. Settings and Design: This was a cross-sectional study carried out in the outpatient department of a tertiary‑level teaching hospital in New Delhi. Materials and Methods: Institutional Ethical Board approval was obtained and written informed consent too was obtained from the participants involved in this study. Persons with best‑corrected vision <20/200 in the better eye, and their primary caregivers, were recruited. We recorded demography, other illness/disability, household income, relationship with disabled person, and caregiver burden (Caregiver Burden Scale) and depression (Centre for Epidemiologic Studies Depression Scale). Statistical Analysis: Statistical analysis was carried out using SPSS version 20 (Released 2011. Armonk, NY: IBM Corp.); range, average, and standard deviation were determined for age, burden, and depression. The association between burden and depression was determined using Pearson’s correlation; the relationship between degree of disability and caregiver burden and depression was determined using unpaired t‑test; using multiple linear regression, factors were found to be statistically significant; significance was taken at P < 0.05. Results: Twenty‑seven (53.0%) men and 24 (47.0%) women had visual impairment. Most caregivers (n = 40; 81.6%) were first‑degree relatives or a spouse; 32 (65%) had schooling <5 years; and 29 (59%) were unemployed. Depression ranged from 21 to 52 (average 43.2 ± 5.71); it correlated with degree of disability (P = 0.012), household income (r = −0.320; P = 0.025), and burden (r = 0.616; P < 0.001). Burden ranged from 30 to 73 (average 54.5 ± 6.73) and correlated with degree of disability (P = 0.006). On multiple linear regression, burden predicted depression (r = 0.557; P < 0.001). Conclusions: Caregivers merit community support, financial benefit, interventions to diagnose and treat depression, and training in coping. Centers that provide disability certification could offer counseling.

Use of subjective and objective criteria to categorise visual disability.

Context: Visual disability is categorised using objective criteria. Subjective measures are not considered. Aim: To use subjective criteria along with objective ones to categorise visual disability. Settings and Design: Ophthalmology out‑patient department; teaching hospital; observational study. Material and Methods: Consecutive persons aged >25 years, with vision <20/20 (in one or both eyes) due to chronic conditions, like cataract and refractive errors, were categorized into 11 groups of increasing disability; group‑zero: normal range of vision, to group‑X: no perception of light, bilaterally. Snellen’s vision; binocular contrast sensitivity (Pelli‑Robson chart); automated binocular visual field (Humphrey; Esterman test); and vision‑related quality of life (Indian Visual Function Questionnaire‑33; IND‑VFQ33) were recorded. Statistical Analysis: SPSS version‑17; Kruskal‑wallis test was used to compare contrast sensitivity and visual fields across groups, and Mann‑Whitney U test for pair‑wise comparison (Bonferroni adjustment; P < 0.01). One‑way ANOVA compared quality of life data across groups; for pairwise significance, Dunnett T3 test was applied. Results: In 226 patients, contrast sensitivity and visual fields were comparable for differing disability grades except when disability was severe (P < 0.001), or moderately severe (P < 0.01). Individual scales of IND‑VFQ33 were also mostly comparable; however, global scores showed a distinct pattern, being different for some disability grades but comparable for groups III (78.51 ± 6.86) and IV (82.64 ± 5.80), and groups IV and V (77.23 ± 3.22); these were merged to generate group 345; similarly, global scores were comparable for adjacent groups V and VI (72.53 ± 6.77), VI and VII (74.46 ± 4.32), and VII and VIII (69.12 ± 5.97); these were merged to generate group 5678; thereafter, contrast sensitivity and global and individual IND‑VFQ33 scores could differentiate between different grades of disability in the five new groups. Conclusions: Subjective criteria made it possible to objectively reclassify visual disability. Visual disability grades could be redefined to accommodate all from zero‑100%.

The Effect of Conventional Hormone Therapy and Tibolone on Tear Composition and Function in Postmenopausal Women.

Objective: To compare the effects of conventional hormonal therapy (HT) and tibolone on tear composition and tear function. Material and methods: Prospective randomized study in 60 postmenopausal women who received conventional HT versus tibolone for postmenopausal symptoms. Response assessed on Kupperman index, eye symptoms and qualitative and quantitative tests for tears at six months follow-up. Quantitative data analyzed using Student’s t-test, ANOVA test, Fisher’s exact test and qualitative data by using McNemar-Bowker test with Bonferroni correlation and Kappa test. Results: There was a significant improvement in the mean Kupperman scores with conventional HT and tibolone (p < 0.01). Tibolone effectively reduced foreign body sensation but there was no appreciable change in other eye symptoms with both therapies. P value did not show any significant change in quantitative tests (Schirmer’s I and II) and qualitative tests (break-up time) for tear secretion. Tear immunoglobulin A level was significantly elevated with both therapies. Conclusion: Conventional HT or tibolone did not have any significant beneficial effect on tear composition and tear function. A larger study can be undertaken using systemic or topical estrogen or androgen containing preparation for further evaluation for dry eye symptoms.

Behcet's disease in India: A dermatological perspective.

Background : Behcet's disease (BD) is a chronic, recurrent, multi-system inflammatory disorder involving mucocutaneous (MC), ocular, intestinal, articular, vascular, urogenital and neurologic systems. BD occurs with a high prevalence in the Mediterranean population. There is scarcity of clinical data on BD from India with only three case series in the last two decades. Aims: To study demographic profile, clinical manifestations and treatment outcome of patients with BD presenting to the dermatologic clinic in a tertiary hospital in north India. Methods: Prospective analysis of all patients diagnosed to have BD between 1997 to 2011. Result: Twenty nine patients were diagnosed to have BD. The disease had a female preponderance (M:F = 1:3.8) with a mean age of disease onset of 27.4 (range 16-61) years. The prevalence of various MC and systemic manifestations are as follows: oral aphthae (100%), genital aphthae (93.1%), erythema nodosum (62%), papulopustular and acneiform lesions (31%), articular involvement (68.9%), ocular involvement (31%) and gastrointestinal (GI) involvement (3.4%) . Pathergy test positivity was observed in 31%. The treatment comprised of colchicine (16/29 patients), dapsone (7/29), dapsone with pentoxiphylline (3/29), systemic steroid (2/29), systemic steroid with methotrexate (1/29). Colchicine was effective and well tolerated in all patients. Conclusion: The disease occurs in a much milder form in India and is primarily mucocutaneous and arthritic. A high index of suspicion in patients with MC lesions may result in early diagnosis, management and prevention of complications of BD. We suggest colchicine as an effective and safe therapeutic option for MC and joint involvement.

Epidermal nevus syndrome associated with unusual neurological, ocular, and skeletal features.

Epidermal nevus syndrome (ENS) is a rare disease, the pathogenesis of which is largely elusive. We, hereby, report an exclusive case of a 20-year-old man with verrucous ENS presented with dark colored papules and plaques along the Blaschko's lines present over the head and neck area along with fleshy growth in both eyes since birth. Limb length discrepancy and kyphoscoliosis were remarkable. Skin biopsy was compatible with verrucous epidermal nevus while the biopsy of the ocular lesion confirmed complex choristoma. MRI brain revealed calcification in the right temporal lobe. Bilateral arachnoid cyst in the middle cranial fossa, scleral osteoma in the posterior part of the right eyeball, and deformed calvarium were evident on CECT skull and orbit. The present illustration emphasizes the importance of a punctilious work up of the case.

Are current guidelines for categorization of visual impairment in India appropriate.

Context: Visual disability in India is categorized based on severity. Sometimes the disabled person does not fit unambiguously into any of the categories. Aims: To identify and quantify disability that does not fit in the current classification, and propose a new classification that includes all levels of vision. Settings and Design: Retrospective chart review of visual disability awarded in a teaching hospital. Materials and Methods: The last hundred records of patients who had been classified as visually disabled were screened for vision in both eyes and percentage disability awarded. Data were handled in accordance with the Helsinki Declaration. Results: Twenty-one patients had been classified as having 30% disability, seven each had 40% and 75%, and 65 had 100% disability. Eleven of them did not fall into any of the current categories, forcing the disability board to use its own judgment. There was a tendency to over-grade the disability (seven of 11; 63.6%). The classification proposed by us is based on the national program for control of blindness' definition of normal vision (20/20 to 20/60), low vision (<20/60 to 20/200), economic blindness (<20/200 to 20/400) and social blindness (<20/400). It ranges from the mildest disability (normal vision in one eye, low vision in the other) up to the most severe grade (social blindness in both eyes). Conclusions: The current classification of visual disabilities does not include all combinations of vision; some disabled patients cannot be categorized. The classification proposed by us is comprehensive, progresses logically, and follows the definitions of the national program.

Cutaneous tuberculosis and phlyctenular keratoconjunctivitis: a forgotten association.

Cutaneous tuberculosis may be associated with concurrent systemic foci in the body such as lung, lymph node, bone or CNS. Phlyctenular keratoconjunctivitis (PKC) is a manifestation of immunological response to a variety of antigens in the eye, tubercular focus (evident or occult) being the commonest in India. Reports in the existing literature have shown lungs and lymph nodes to be the predominant underlying focus associated with PKC, whereas cutaneous tuberculosis has seldom been found in this situation. We report this forgotten association in two children with cutaneous tuberculosis, one each with lupus vulgaris and scrofuloderma, who also had PKC. Interestingly, one of the cases also had simultaneous lichen scrofulosorum, which is also an immunological response to tubercular antigen and manifests in the skin, thus showing immunological manifestation in two different organ systems along with cutaneous focus of tuberculosis.

Retinopathy of prematurity--risk factors.

OBJECTIVE: Improved survival of low birth weight, premature babies have increased the incidence of retinopathy of prematurity. This hospital-based, prospective, study was undertaken to determine its incidence and risk factors in our neonatal unit. METHODS: Neonates with gestational age < or = 35 weeks and/or birth weight < or = 1500 gm born over a one-year period were examined by indirect ophthalmoscopy between 2 to 4 weeks after birth, and followed up till retinal vascularisation was complete. Maternal and neonatal risk factors were noted and data analyzed by statistical package SPSS-10.0. RESULTS: Sixty babies were thus examined. The incidence of retinopathy was 21.7% in the cohort, 33.3% in babies < or = 32 weeks gestation and 36.4% in babies weighing < or = 1250 gm. Oxygen (p=0.01), sepsis (p=0.04) and apnoea (p=0.02) were independent risk factors. Retinopathy was significantly more severe in babies with hyaline membrane disease (p=0.02) and lower birth weight (p=0.02). Severe disease was never seen before 6.5 weeks of age. CONCLUSION: Indirect ophthalmoscopy should be performed at 4 weeks of post natal age in all preterm babies with birth weight < or = 1500 gm, and intensified in the presence of risk factors like oxygen administration, apnoea and septicemia.

Ocular manifestations of Behcet's disease in Indian patients.

PURPOSE: To study the prevalence, manifestations and severity of ocular involvement in Indian patients with Behcet's disease. METHOD: Prospective analysis of all patients of suspected Behcet's disease between 1997 and 2001. RESULTS: A total of 19 patients were diagnosed to have Behcet's disease. Ocular manifestations were seen in 36% patients. The commonest manifestation was conjunctival ulcer (26.3%), followed by iridocyclitis (10.5%). None of the patients had posterior segment involvement or visual loss. Response to topical corticosteroids was good. CONCLUSION: The prevalence and severity of ocular lesions in Behcet's disease is relatively low in Indian patients. Conjunctival ulcers was a common finding, which is rarely reported in the world literature.