ABSTRACT
Introduction: Rhino-orbito-cerebral Mucormycosis (ROCM) is an uncommon but devastating fungal infection caused by Mucoraceae family fungi, which are angiotropic and filamentous, with significantly high morbidity and mortality despite treatment. Post Coronavirus Disease-2019 (COVID-19), there was a sudden surge in ROCM cases nationwide due to immunologically and metabolically compromised status. Aim: To describe retinal manifestations in ROCM in a tertiary eye care centre of Northern India. Materials and Methods: An analytic, cross-sectional and hospital-based study was conducted in Regional Institute of Ophthalmology, PGIMS Rohtak, Haryana, India, from May 2021 to September 2021. This study was conducted on 200 admitted patients of RCOM in the institute, which was only designated Nodal centre in Haryana, India. Detailed history was recorded in every patient regarding presenting symptoms, history of COVID-19, hospital stay, oxygen inhalation, steroid intake and immunisation. Thorough ocular examination was done in every patient including visual acuity, ocular movements and pupillary reactions. Dilated fundus examination was done by Indirect Ophthalmoscopy (IDO) for posterior segment evaluation. Contrast Enhanced Magnetic Resonance Imaging (CE-MRI) brain with orbit and Paranasal Sinus (PNS) was done in every patient to see the extent of spread and planning further management. Results: Out of 200 patients of ROCM, majority of patients (64/200) were of 51-60 year age group (32%) followed by 41-50 year age group (28%). Out of 200 cases of ROCM, 146 patients (73%) had history of COVID-19 infection in past and 134 (67%) patients had history of hospital stay during COVID-19 infection. Oxygen (O2) supplementation was given to 98 patients either at home or during hospital stay. History of steroid intake was present in 34 patients and 46 patients received injection Remedsivir. Only 12 patients had vaccine against COVID-19 and none of them were fully vaccinated. Most common presenting symptom was unilateral nasal stiffness (22%) followed by loss of vision (17%). Most common predisposing factor was Diabetes Mellitus (DM) in 78 patients (39%) followed by steroid intake in 34 patients (17%). Out of 200 patients, only 60 patients had retinal manifestations and most common was Central Retinal Artery Occlusion (CRAO) (35/60) and the main mechanism is the direct infiltration of central retinal artery due to angioinvasion of fungi from the orbit. Conclusion: CE-MRI brain with orbit is an important tool in diagnosing and monitoring progression of RCOM but it cannot provide information regarding retinal findings like CRAO, central retinal venous occlusion (CRVO), disc pallor and optic atrophy. Thus, the fundus examination of every ROCM patient should be emphasised, as it not only helps in categorising ROCM but also tells about the visual potential of affected eye. Patients with CRAO and combined vascular occlusion should be considered for exenteration on urgent basis, so that intracranial spread can be prevented and patient's life can be saved.
ABSTRACT
Objectives: The mainstay of care in severe traumatic brain injury (TBI) includes time-critical delivery of effective medical and surgical interventions. This is streamlined by Code Black trauma calls at our Major Trauma Centre (MTC). The Covid- 19 pandemic placed unprecedented strain on resources within healthcare and the wider society. The aim of this study was to analyse its effects on the presentation and management of time-critical TBI. Design: Retrospective analysis of the prospective database. Subjects: Patients with severe TBI who triggered Code Black trauma calls from January 2019 until December 2020. Code Black is activated by Glasgow Coma Scale (GCS) ≤ 8, severe mechanism of injury, and changes in pupillary reactivity. Methods: Demographics, clinical, radiological, and surgical findings were collected from medical records and the Trauma and Audit Research Network (TARN);socioeconomic data from the Office for National Statistics. We compared 2019 to the pandemic in 2020. Results: There were 58 and 62 Code Black activations, respectively in 2019 and 2020. During the pandemic, more patients were male (83.9 vs. 65.5%, p = 0.02), and more injuries alcohol-related (33.9 vs. 19.0%) and intentional (19.4 vs. 8.6%). The hospital stay was shorter (21 vs. 32 d). The index of multiple deprivations (IMD) was one decile lower in 2020 (p = 0.036). The mechanism, severity, intracranial findings, timeliness of care, and mortality remained unchanged. Surgical intervention was performed in two-thirds of patients and was associated with higher survival (68.0%) vs. non-surgical treatment (40.0%, p = 0.003). Predictors of in-hospital mortality included increasing age, injury severity, and pupillary changes. Conclusions: The Covid-19 pandemic brought a change to the pattern of time-critical TBI and disproportionately affected lower socioeconomic groups. Although the volume of work remained unchanged, we maintained high-quality care throughout. This highlights the need to retain trauma services during the Covid-19 pandemic.