Fulminant fungal endogenous endophthalmitis following SARS-CoV-2 infection: A case report.

Systemic corticosteroids and immunocompromised state following SARS-CoV-2 infection can predispose individuals to endogenous endophthalmitis. A 66-year-old gentleman presented with complaints of diminution of vision and redness one week post discharge after hospitalization for COVID-19 infection. Clinical examination suggested fulminant endogenous endophthalmitis which responded poorly even after aggressive treatment requiring evisceration. Culture and gene sequenced analysis confirmed Aspergillus fumigatus to be the causative organism. A high degree of suspicion is warranted in the presence of recent onset of floaters in COVID-19-infected individuals to facilitate early diagnosis and outcomes.

Endogenous Fungal Endophthalmitis in a Patient Admitted to Intensive Care and Treated with Systemic Steroid for COVID-19

A 61-year-old woman presented to our clinic with complaints of decreased visual acuity, pain, and redness in her left eye. Best corrected visual acuity (BCVA) was 20/20 in the right eye and counting fingers at 3 meters in the left eye. On slit-lamp examination, 1+ cells were detected in the anterior chamber. Fundus examination revealed 1+ haze in the vitreous and multiple creamy-whitish lesions in the retina and vitreous. Her history included a diagnosis of coronavirus disease 2019 (COVID-19) one month earlier, for which she was hospitalized in the intensive care unit for 20 days and received systemic corticosteroid treatment. Vitreous culture yielded Candida albicans. The patient's nasopharyngeal swab sample was positive for COVID-19 by reverse transcription polymerase chain reaction test. BCVA was improved to 20/40 after amphotericin therapy (via intravitreal injection and intravenous routes), and the vitritis and chorioretinitis lesion regressed after 2 weeks of treatment. Two weeks later, intravenous amphotericin was discontinued and oral fluconazole treatment was started at a dose of 400 mg/day. At 3-month follow-up, her BCVA was 20/25 and no inflammatory reaction was observed in the anterior chamber and vitreous.

Clinico-Radiological-Pathological Correlation of Visual Loss in COVID-Associated Rhino-Orbito-Cerebral Mucormycosis.

PURPOSE: To correlate the clinical, radiological, and histopathological features in Covid-associated Rhino-orbito-cerebral mucormycosis cases presenting with acute visual loss. DESIGN: Cross-sectional study. METHODS: Covid-associated Rhino-orbito-cerebral mucormycosis cases with unilateral visual loss, planned for exenteration, underwent orbital and ophthalmological ocular examination. The available radiological sequences, doppler ultrasonography and histopathology findings were correlated with clinical manifestations. RESULTS: The median age was 51 years and the male: female ratio was 3:1. All except one presented with unilateral ophthalmoplegia. The ocular media were hazy in 2 eyes. In 8 eyes, retinal changes were suggestive of occlusion of CRA (6), combined occlusion of CRA and central retinal vein (1), and myopic degeneration with hypertensive retinopathy (1). The contralateral eye showed retinal ischemic changes in one patient. Radiological imaging showed orbital apex involvement in the 10 affected eyes and one contralateral eye. Ipsilateral cavernous sinus thrombosis, diffusion restriction on MRI of optic nerve, internal carotid artery narrowing/thrombosis, and cortical watershed infarcts were seen in 8, 4, 4, and 2 cases, respectively. The blood flow in CRA and ophthalmic artery was absent or reduced in all the 10 affected eyes and in 1 contralateral eye. On histopathology, orbital fat necrosis, fungal hyphae, acute inflammation, granuloma formation, ischemic thrombosis of ophthalmic artery was observed in 10 specimens. CRA was patent in 9 and thrombosed in 1 eye. Optic nerve was ischemic in 8 and viable in 2 eyes. CONCLUSION: Acute visual loss in ROCM cases is associated with orbital apex involvement and thrombotic ischemia of ophthalmic artery. Cessation of flow in CRA possibly occurs secondary to ophthalmic artery thrombosis.

Rhino-orbital-cerebral mucormycosis: fungal epidemic in a viral pandemic.

BACKGROUND: Treatment of coronavirus disease 2019 infection can result in immunosuppression. Rhino-orbital-cerebral mucormycosis is a frequent co-infection, even after recovery. METHODS: An ambispective interventional study was conducted of 41 coronavirus patients with rhino-orbital-cerebral mucormycosis at a tertiary care centre from March to May 2021. RESULTS: There were 28 males and 13 females with a mean age of 48.2 years (range, 21-68 years). Twelve had long-standing diabetes mellitus and 28 had been recently diagnosed. Thirty-six had received systemic corticosteroids for coronavirus disease 2019. Nasal signs were present in 95 per cent of patients, ophthalmic symptoms and signs in 87 per cent, palatal necrosis in 46.3 per cent, facial signs in 24.3 per cent, nerve palsies in 60.9 per cent, and intracranial involvement in 21.9 per cent. Treatment with amphotericin B was based on clinical features and co-morbidities. Endonasal debridement was performed in 51.2 per cent of patients, total maxillectomy in 14.6 per cent and orbital exenteration in 9.7 per cent. At the last follow up, 37 patients (90.24 per cent) were on antifungal therapy; 4 (9.75 per cent) did not survive. CONCLUSION: Early detection may improve survival. Follow up of high-risk patients after coronavirus disease 2019 infection is paramount.

Post-COVID-19 rhino-orbito-cerebral mucormycosis: a new addition to challenges in pandemic control.

OBJECTIVE: To document and analyse demographic data, clinical presentation, possible interventions for early clinical detection and management of post-COVID-19 rhino-orbito-cerebral mucormycosis (ROCM). METHOD: 32 patients having history of SARS-CoV-2 infection with features of ROCM were observed in terms of their history, presenting features, clinical, microbiological examination, type of surgical intervention, surgical sites of involvement which were subsequently analyzed. RESULTS: The mean (± S.D.) age of patients was 57 ± 13 years. All patients were diabetic. Mean (± S.D.) time of onset of ROCM symptoms, since onset of COVID-19 symptoms was 18 (± 4) days. 12.5% patients were fully vaccinated. 78.1% patients received steroid therapy; 28.1% received high flow nasal oxygen. 87.5% patients had blurring of vision, 65.62% headache, 59.37% cheek and eyelid swelling, 50% proptosis, 46.87% ophthalmoplegia, 40.62% ptosis, 40.62% loss of sensation over cheek, 25% orbital pain. Examination of specimen with KOH mount revealed Mucor spp. in all patients. 87.5% patients underwent endoscopic sinus surgery with debridement with/without orbital clearance; 56.25% maxillectomy; 25% orbital exenteration. 87.5% patients had paranasal sinus involvement, 43.75% orbit sparing orbital apex, 68.75% orbit with orbital apex. 81.25% patients had involvement of pterygopalatine fossa±infratemporal fossa. 50% patients had disease in Vidian canal and pterygoid wedge. 25% of patients had involvement of palate and 56.25% cheek and eyelid soft tissues. CONCLUSION: A judicious COVID treatment protocol, high index of suspicion, close monitoring of high-risk patients and early institution of treatment can prevent case severity and reduce mortality.

Impact of COVID-19 Pandemic on Infectious Keratitis Outcomes: A Retrospective Multicenter Study in Tertiary Eye Hospitals of South India.

PURPOSE: The purpose of this study was to report the adverse effects of the COVID-19 pandemic on the clinical outcomes of infectious keratitis in South India. METHODS: Two hundred fifty-eight patients presented with infectious keratitis at 6 tertiary care centers when strict travel restrictions were in place from March 24 to May 31, 2020. Case records were collected retrospectively and analyzed for demographics, type of initial treatment, length of delay in presentation, microbiological diagnosis, clinical course, and final treatment outcome. RESULTS: The mean age of the patients was 49.2 years, with most of them (61.2%) being male. Forty-one patients (15.9%) did not receive any treatment for at least a week after the onset of symptoms. One hundred eight patients (41.9%) presented with severe ulcer (32 had a frank perforation). Resolution of the infection was achieved only in 103 patients (45.6%). A total of 90 patients (39.8%) with ulcers had a perforation, yet only 29 patients (32.2%) could receive keratoplasty because of the unavailability of donor tissues. At the end of 6-month follow-up, 47 patients had anatomical failure (loss of globe) and 12 additional patients had functional failure (total permanent vision loss). CONCLUSIONS: Delay in presentation and acute shortage of donor corneal tissues for emergency keratoplasty because of the COVID-19 pandemic had a grave impact, resulting in irreversible blindness in a significant number of patients.

Endogenous Endophthalmitis A Complication of COVID-19 Pandemic: A Case Series.

PURPOSE: To report six patients with endogenous endophthalmitis as a complication of COVID-19 infection. METHODS: A multicentric retrospective database review of patients with a diagnosis of endogenous endophthalmitis and a history of COVID-19 infection. RESULTS: Four of six patients were diabetics. All presented after an average duration of 40 days (Range 17-90 days) of COVID-19 infection. Two of six patients had bilateral involvement. Five of six patients had received intravenous corticosteroid for COVID-19. Two of six vitreous samples showed fungi (Candida and Bipolaris species), two showed bacteria (Staphylococcus species) and two samples were culture negative. Control of infection with good visual outcome in four out of eight eyes. CONCLUSIONS: COVID-19 patients with a history of hospitalization and prolonged use of systemic corticosteroids and comorbidities, for example, diabetes mellitus have a high risk of endogenous endophthalmitis. A high index of clinical suspicion with timely intervention can salvage many eyes.

Post COVID-19 opportunistic candida retinitis: A case report.

A 42-year-old male patient presented with profound impairment of vision in both eyes, just as he was recovering from COVID-19. A known diabetic and hypertensive, he suffered from COVID-19 pneumonia further complicated by ARDS, septicaemia and acute kidney injury. His vision on presentation was finger counting close to face bilaterally with multiple, yellowish lesions at the posterior pole. Based on the clinical findings and previous blood culture report, it was diagnosed as candida retinitis and treated with oral and intravitreal anti-fungals. The lesions were regressing at follow-up. This is a post COVID-19 presumed candida retinitis case report.

Mucor in a Viral Land: A Tale of Two Pathogens.

Purpose: COVID-19 infection, its treatment, resultant immunosuppression, and pre-existing comorbidities have made patients vulnerable to secondary infections including mucormycosis. It is important to understand the presentation, temporal sequence, risk factors, and outcomes to undertake measures for prevention and treatment. Methods: We conducted a retrospective, interventional study on six consecutive patients with COVID-19 who developed rhino-orbital mucormycosis and were managed at two tertiary ophthalmic referral centers in India between August 1 and December 15, 2020. Diagnosis of mucormycosis was based on clinical features, culture, and histopathology from sinus biopsy. Patients were treated with intravenous liposomal amphotericin B with addition of posaconazole and surgical debridement of necrotic tissue. Results: All patients were male, mean age 60.5 ± 12 (46.2-73.9) years, type 2 diabetics with mean blood glucose level of 222.5 ± 144.4 (86-404) mg/dL. Except for one patient who was diagnosed with mucormycosis concurrently with COVID-19, all patients received systemic corticosteroids for the treatment of COVID-19. The mean duration between diagnosis of COVID-19 and development of symptoms of mucor was 15.6 ± 9.6 (3-42) days. All patients underwent endoscopic sinus debridement, whereas two patients required orbital exenteration. At the last follow-up, all six patients were alive, on antifungal therapy. Conclusion: Mucormycosis is a life-threatening, opportunistic infection, and patients with moderate to severe COVID-19 are more susceptible to it. Uncontrolled diabetes mellitus and use of corticosteroids increase the risk of invasive fungal infection with mucormycosis which can develop during the course of the illness or as a sequelae. High index of suspicion, early diagnosis, and appropriate management can improve survival.

Dematiaceous Fungal Colonization of the Bandage Contact Lens in a Patient Lost to Follow-up During the COVID-19 Crisis.

We report a rare case of dematiaceous fungus colonization in the therapeutic bandage contact lens (BCL), in an eye with peripheral ulcerative keratitis. Bandage contact lens removal and appropriate treatment resulted in improvement of the visual acuity and prevented the spread of fungus to the underlying ocular structures. Microbiological evaluation of the BCL showed dematiaceous fungal filaments, and the fungus was identified as Bipolaris species. In patients with pigmented plaque-like lesions, with BCL in situ, dematiaceous fungus on the undersurface of the BCL should be kept in mind. Patient education regarding the importance of frequent BCL replacement, proper ocular hygiene, and timely follow-up should be emphasized.