Incidence, risk factors, progression, and involution in retinopathy of prematurity at a tertiary care center in South India.

BACKGROUND: Retinopathy of prematurity (ROP) is a vasculoproliferative disorder of immature retina, seen in preterm babies. Multiple risk factors attribute to this condition. Our aim was to correlate the role of any early neonatal surgeries with low gestational age (GA) and birth weight (BW) on preterm babies as a risk factor on the progression of ROP. METHODS: A prospective, cohort study conducted in a hospital in South India over 3 years, including 600 babies with GA <35 weeks and BW <2500 g. Babies were divided into Group A (ROP) and Group B (no ROP). Group A included A1 (severe ROP) and A2 (nonsevere ROP) based on early treatment of ROP classification. We compared various risk factors of ROP, specifically the association of any early neonatal surgery undergone by these babies, on progression of ROP. The Chi-square test, unpaired t-test, and one-way analysis of variance tests were used for the comparisons and considered statistically significant if P < 0.05. RESULTS: 28.7% babies developed ROP, with 37.6% requiring treatment (Aggressive ROP in 2.1% of babies). Low GA and BW, longer duration on ventilator, respiratory distress syndrome, apnea of prematurity, Patent Ductus Arteriosus, sepsis, anemia, thrombocytopenia, history of blood transfusion, and history of early neonatal surgery under GA were associated with babies with ROP (P < 0.005), strongly with severe ROP. The most common surgeries undergone by the babies developing ROP were inguinal herniotomy under general anesthesia. CONCLUSION: The study predicts preterm babies undergoing early surgical interventions are at risk of progressing to severe ROP, hence warranting frequent follow-ups.

Clinical association and visual morbidity in uveitis with systemic diseases: An analysis from a tertiary ophthalmic center.

AIM: The aim of this study was to identify the incidence, etiology, most common presentations, complications, and the causes of visual loss in posterior uveitis (PU). MATERIALS AND METHODS: A retrospective study was conducted on a cohort of 125 patients with PU with a minimum follow-up of 6 months. Ocular evaluation consisted of slit-lamp examination, indirect ophthalmoscopy, tonometry, and refraction. Ancillary ophthalmic investigations such as fundus fluorescein angiography, optical coherence tomography, and B-scan ultrasonography were done. Laboratory tests were performed on blood on all patients and in aqueous humor samples obtained by anterior chamber paracentesis in cases of diagnostic dilemmas. All the data were analyzed using SPSS program. RESULTS: PU occurred in 61%. Infections were noted in 34% and autoimmune diseases in 27%. The most frequent presentation was choroiditis. The most common etiologies were tubercular uveitis in 50%, Toxoplasma retinochoroiditis in 23%, and autoimmune category of serpiginous choroiditis in 56% of patients. Complications occurred in 27% and were most commonly cystoid macular edema and macular scarring. Polymerase chain reaction (PCR), nested PCR, and real-time PCR on ocular fluids were required for diagnosis in 30%. A combination of laboratory investigations on blood and aqueous humor samples were confirmation in 88%. CONCLUSION: PU and its sequelae are known to be sight threatening and are associated with systemic diseases. They have diverse etiologies and presentations. Identification of etiology is important as management is diametrically opposite in infections and autoimmune diseases.

Satellite Epidemic of Covid-19 Associated Mucormycosis in India: A Multi-Site Observational Study.

BACKGROUND: Sudden upsurge in cases of COVID-19 Associated Mucormycosis (CAM) following the second wave of the COVID-19 pandemic was recorded in India. This study describes the clinical characteristics, management and outcomes of CAM cases, and factors associated with mortality. METHODS: Microbiologically confirmed CAM cases were enrolled from April 2021 to September 2021 from ten diverse geographical locations in India. Data were collected using a structured questionnaire and entered into a web portal designed specifically for this investigation. Bivariate analyses and logistic regression were conducted using R version 4.0.2. RESULTS: A total of 336 CAM patients were enrolled; the majority were male (n = 232, 69.1%), literate (n = 261, 77.7%), and employed (n = 224, 66.7%). The commonest presenting symptoms in our cohort of patients were oro-facial and ophthalmological in nature. The median (Interquartile Range; IQR) interval between COVID diagnosis and admission due to mucormycosis was 31 (18, 47) days, whereas the median duration of symptoms of CAM before hospitalization was 10 (5, 20) days. All CAM cases received antifungal treatment, and debridement (either surgical or endoscopic or both) was carried out in the majority of them (326, 97.02%). Twenty-three (6.9%) of the enrolled CAM cases expired. The odds of death in CAM patients increased with an increase in HbA1c level (aOR: 1.34, 95%CI: 1.05, 1.72) following adjustment for age, gender, education and employment status. CONCLUSION: A longer vigil of around 4-6 weeks post-COVID-19 diagnosis is suggested for earlier diagnosis of CAM. Better glycemic control may avert mortality in admitted CAM cases.

A case control investigation of COVID-19 associated mucormycosis in India.

BACKGROUND: Increased occurrence of mucormycosis during the second wave of COVID-19 pandemic in early 2021 in India prompted us to undertake a multi-site case-control investigation. The objectives were to examine the monthly trend of COVID-19 Associated Mucormycosis (CAM) cases among in-patients and to identify factors associated with development of CAM. METHODS: Eleven study sites were involved across India; archived records since 1st January 2021 till 30th September 2021 were used for trend analysis. The cases and controls were enrolled during 15th June 2021 to 30th September 2021. Data were collected using a semi-structured questionnaire. Among 1211 enrolled participants, 336 were CAM cases and 875 were COVID-19 positive non-mucormycosis controls. RESULTS: CAM-case admissions reached their peak in May 2021 like a satellite epidemic after a month of in-patient admission peak recorded due to COVID-19. The odds of developing CAM increased with the history of working in a dusty environment (adjusted odds ratio; aOR 3.24, 95% CI 1.34, 7.82), diabetes mellitus (aOR: 31.83, 95% CI 13.96, 72.63), longer duration of hospital stay (aOR: 1.06, 95% CI 1.02, 1.11) and use of methylprednisolone (aOR: 2.71, 95% CI 1.37, 5.37) following adjustment for age, gender, occupation, education, type of houses used for living, requirement of ventilatory support and route of steroid administration. Higher proportion of CAM cases required supplemental oxygen compared to the controls; use of non-rebreather mask (NRBM) was associated as a protective factor against mucormycosis compared to face masks (aOR: 0.18, 95% CI 0.08, 0.41). Genomic sequencing of archived respiratory samples revealed similar occurrences of Delta and Delta derivates of SARS-CoV-2 infection in both cases and controls. CONCLUSIONS: Appropriate management of hyperglycemia, judicious use of steroids and use of NRBM during oxygen supplementation among COVID-19 patients have the potential to reduce the risk of occurrence of mucormycosis. Avoiding exposure to dusty environment would add to such prevention efforts.

Visual morbidity and spectrum of ophthalmic changes in pregnancy induced hypertension.

Aim: To determine the prevalence of ocular changes in pregnancy-induced hypertension (PIH) and co-relate the ophthalmic changes and severity of the disease with visual outcome. Methods and Material: This is a retrospective study conducted from a hospital-based cohort of pregnant women, who delivered from June 2018 to December 2020. A total of 153 patients who fulfilled the diagnostic criteria of PIH admitted in the obstetric ward were included in this study. History with regard to age, parity, gravida, gestational age, medical history, and ocular findings were noted from the patient's case records. Anterior segment examination, dilated fundus evaluation, blood pressure (BP) recordings, urine proteinuria were done. All data were analyzed using the satistical package for social science (SPSS) program. Results: Out of 153 patients, 78 (50.98%) were primigravida, 55 (35.95%) were gravida 2, and 20 (13.07%) were multigravida. Gestational age ranged from 23-40 weeks. Ocular changes were seen in 57% of the PIH patients. Hypertensive retinopathy was seen in 23.53% of PIH patients with a mean age of 29.06 ± 4.36 years. Grade 1 hypertensive retinopathy was the most common manifestation in PIH patients (51.16%). The visual loss occurred in 72% of eclampsia and12% of pre-eclampsia which was statistically significant (P = 0.03). Papilledema was seen in 6% and refractive error in 41% of the patients. Conclusions: Ocular examination of PIH patients reveals important objective information concerning the disorder. The presence of retinal change is a marker of the severity of PIH and is the most common ocular feature. Detection of progression of these changes reflects ischemic changes of the placenta. Fundus examination in PIH patients is important to predict adverse fetal outcomes, and risks to mother's life.

Newer trends in tubercular uveitis: a case series with systemic correlation.

AIM: To determine the spectrum of uveitis, causes of visual loss in systemic tuberculosis (TB), role of investigations and outcome after anti-TB therapy (ATT). METHODS: A retrospective study was conducted on 250 patients with systemic TB at a referral center in Chennai, South India from April 2016 to May 2019. Systemic workup comprised of Mantoux, chest X-ray, polymerase chain reaction (PCR) and QuantiFERON (QFT) TB Gold. Aqueous humor analysis by nested PCR or real time PCR (RT-PCR) and ancillary ophthalmic investigations such as fundus fluorescein angiography, optical coherence tomography were performed. RESULTS: Multifocal choroiditis and vasculitis were the most common manifestations (39% and 24% respectively) together accounting for 61% of cases and they had a higher risk of recurrence (3%). Pulmonary tuberculosis (PTB) was more frequently associated with uveitis (18%). Among those with extra-pulmonary tuberculosis (EPTB), uveitis occured in miliary TB (2%), bone (1%) and abdominal TB (1%). Complications such as cystoid macular edema, choroidal neovascular membranes and macular scarring caused visual loss. Aqueous humor analysis detected mycobacterium TB antigen. Collectively, systemic investigations such as chest X-ray, Mantoux test and those performed on blood samples such as PCR and QFT were positive in 39% of patients. In inconclusive patients, nested PCR and/or RT-PCR were done on aqueous humor samples and were diagnostic in 96%. A combination of tests was diagnostic in 92%. ATT in isolation in 71% and combined with corticosteroids in 29% was used for treatment of which signs of resolution and improvement in vision started as early as 6wk in those who were started immediately on corticosteroids and ATT and longer than 3mo in those on ATT alone. Prompt treatment with ATT and corticosteroids improved vision in 23% of our patients within 2mo. Vitritis with choroiditis causes cystoid macular oedema and requires longer duration of ATT. Vision improved in 69%. Complete resolution occurred in 75% and worsening in 12%. CONCLUSION: A combination of investigations guided by clinical suspicion helps in precise diagnosis. In diagnostic dilemmas analysis of ocular samples is reliable and confirmatory. Screening all patients and a multidisciplinary approach in TB (active, healed or during treatment) is recommended.

Intraocular biopsy in uveitis.

An intraocular biopsy is performed for diagnostic, prognostic and investigational purposes. Biopsies help to confirm or exclude malignancies and differentiate inflammatory from infectious processes. Histopathological analysis is the final verdict in unresponsive uveitis, atypical inflammation, metastases and masquerade syndromes. Advances and refinement of techniques in cytopathology, immunohistochemistry, microbiological and molecular biologic study offer much more than just diagnosis. They provide prognosis based on cell characteristics and are helpful in planning treatment and intervention. Many biopsy procedures have evolved to provide more safety and minimise complications thus improving the quality of specimens or samples available for analysis. The type of biopsy and technique adopted varies based on the clinical suspicion, size and location of lesions. In uveitis, a working diagnosis of intraocular inflammation is made on clinical examination and laboratory investigations and ancillary tests. Malignancy and uveitis is interlinked and masquerade syndromes are among the commonest indications for biopsy and analysis of specimen. The various types of intraocular biopsies include aqueous tap, fine needle aspiration biopsy, vitreous biopsy, iris and ciliary body, and retinochoroidal biopsy. They will be reviewed in this article with respect to current perspective.

Uveitis in sporadic Blau syndrome: Long-term follow-up of a refractory case treated successfully with adalimumab.

The classic entity of autosomal dominant Blau syndrome (BS) consists of arthritis, dermatitis, and uveitis, occurring as a result of mutations in the NOD2 gene pattern recognition receptor. Sporadic cases are those in which no known gene mutation is identifiable. Uveitis in BS can be refractory to conventional therapy. We report a case of sporadic Blau uveitis managed with adalimumab monotherapy after failing to respond to topical steroids, systemic steroids, methotrexate, and infliximab therapy sequentially. Uveitis resolved completely with adalimumab and the patient has had a disease-free period over a 2-year follow-up with bi-monthly injections for arthritis control.

Laboratory investigations in uveitis: current practice and future directions.

Diagnosis and management of uveitis always remains a challenge to the treating ophthalmologists. Rapid diagnosis and timely initiation of appropriate, effective treatment in uveitis are the critical determinants that lead to good visual outcome and reduce the risk of ocular morbidity. In the last decade, significant progress has been made in molecular diagnostic modalities and in development of newer diagnostic tools, which included serological tests and imaging techniques. However, a tailored approach to laboratory investigations based on meticulous history and comprehensive ocular evaluation has been propounded as the gold standard for successful management of an uveitic entity. In this article, we review the laboratory diagnostic tests in uveitis as well as recent technological advances in laboratory science, which may be the future direction for diagnosis of uveitis.

Sympathetic ophthalmia presenting with signs of frosted branch angiitis: Report of a case.

Sympathetic ophthalmia is an ocular inflammatory disease commonly associated with penetrating trauma. We report a case of sympathetic ophthalmia who had Dalen-Fuchs nodules on presentation and developed a frosted branch angiitis (FBA)-like picture which is not a known feature of this disease. A 25-year-old male patient was seen 8 months following penetrating trauma to the left eye. He was treated with oral steroids and immunosuppressives. Fundus fluorescein angiography confirmed the presence of perivascular retinitis; optical coherence tomography showed retinal thickening and ultrasonography showed peripapillary choroidal thickening. Atypical features such as FBA in cases of sympathetic ophthalmia can be present and can indicate an ongoing active inflammation. Early aggressive management is required to prevent visual morbidity.

Patterns of Intermediate Uveitis in Children Presenting at a Tertiary Eye Care Center in South India.

PURPOSE: To study the patterns of intermediate uveitis in the pediatric age group in a referral eye care center in South India. METHODS: This is a study of twenty consecutive patients under 16 years of age with intermediate uveitis, conducted at a tertiary referral center. Numerous variables were assessed, including age and gender distribution, laboratory data, the presence of systemic diseases, onset and course of ocular inflammation, clinical features, their complications, therapeutic strategies with their outcomes, remission, final visual acuity (VA), and characteristics associated with poor visual outcome. RESULTS: Bilateral involvement was observed in 80% of the patients. Remission was observed in five out of 7 patients (78%) with completed follow-up of 5 years. Final VA improved by at least two lines in 11 patients, remained stable in 6 patients, and worsened in 3 patients. The etiological diagnosis showed one patient with Bechet's disease, one with juvenile idiopathic arthritis, 1 with human leukocyte antigen B27 associated uveitis, 9 with laboratory proven tuberculosis, and 3 with sarcoidosis and 5 where it was idiopathic. The mean follow-up was 4.8 years (range 3-8 years). Cataract was the most frequent complication observed (40%). Glaucoma, choroidal neovascularization, and amblyopia accounted for worsening of vision in three patients. CONCLUSION: Median time of development of complications is about 3 years based on our study. Intermediate uveitis of childhood might exhibit a self-limiting course after several years. Visual recovery is good in the majority, and visual loss is limited despite the high rate of ocular complications.

Bilateral choroidal tuberculoma in miliary tuberculosis - report of a case.

BACKGROUND: A choroidal mass or granuloma is a feature of ocular tuberculosis (TB). Tubercles can arise in the early stages of progression of TB and indicate hematogenous dissemination before the development of symptomatic disease. Tubercular subretinal granuloma is responsive to treatment with anti-tuberculosis therapy, and prompt treatment helps resolve the lesion completely. FINDINGS: We report a case of a solitary large active choroidal tuberculoma in one eye and multiple healed tubercles in the other. The patient was an immunocompetent girl with splenic and miliary TB and had a relatively asymptomatic systemic status. Aqueous humor analysis by polymerase chain reaction (PCR) and real-time PCR (RT-PCR) was negative for the Mycobacterium tuberculosis genome. Based on clinical history and investigations, treatment with four-drug regimen of anti-tubercular treatment with concomitant corticosteroids was started, and total healing of the lesion occurred in 3 months. CONCLUSIONS: This case highlights the fact that in some patients, analysis of the aqueous may not provide any clue to the confirmation of an active tubercular choroidal granuloma and an association between splenic tuberculosis and choroidal tubercles has never been reported in the past.

Clinical Features, Investigations, Management, and Prognosis of Serpiginous Choroiditis.

Serpiginous choroiditis is an inflammatory form of posterior uveitis that affects the choroid, retinal pigment epithelium, and choriocapillaries. Known to be recurrent and progressive in nature, this bilateral disease can result in severe visual loss both during the active and healed stages. The age at onset is 40 to 50 years, but it can affect younger Indian population. It can be further classified into 3 types based on its clinical presentation, and they are, namely, peripapillary, macular, and ampiginous. Histological features further qualify the site of inflammation as evidenced by lymphocytic infiltration within the choroid and atrophy of choriocapillaries and retinal pigment epithelium. Despite a multitude of etiologies such as autoimmunity, infection, and degeneration, autoimmune causes remain the mainstay. Laboratory investigations can help rule out infections, whereas angiography can provide further insights into the progression of the disease. Newer investigations such as optical coherence tomography and fundus autofluorescence can help locate the lesion and identify the phase of the disease. Corticosteroids with immunosuppressives are the major management modality. Treatment of complications may require intravitreal injections, laser photocoagulation, or even vitreoretinal surgery.

Tuberculous scleritis in a patient with rheumatoid arthritis.

UNLABELLED: Scleritis is an ocular inflammatory disorder commonly associated with systemic autoimmune diseases. We report a case of nodular scleritis with an etiological diagnosis of tuberculosis wherein diagnosis was possible only after histopathological examination of the enucleated eye. METHOD OF STUDY: A 52 year female patient was referred as a case of nodular scleritis not responding to topical and oral anti-inflammatory agents. She was being treated with immunosuppressives for rheumatoid arthritis by her rheumatologist. Scleritis improved initially but worsened in few months with development of complications. Eye was enucleated and histopathological examination revealed tuberculous bacilli in retinal pigment epithelial cells. CONCLUSION: Infective scleritis should be suspected in cases of scleritis which progress despite treatment. Reactivation of latent Mycobacterium tuberculosis may occur especially in patients on long term systemic immunosuppressive treatment. Early detection and aggressive treatment is necessary for preventing morbidity or mortality due to these infections.

Intraocular parasitic infections.

A parasite is a living organism that receives some of its basic nutritional requirements through intimate contact with another living organism. When the parasite reaches the eye, ocular complications occur due to mechanical, immunologic, or allergic reactions. When an ophthalmologist detects a parasite in the eye, it is often difficult to identify the exact organism. Lack of methodological uniformity in management of ocular parasitosis emphasizes the need for standardization, including construction of a management algorithm. Knowledge on immunoreactivity in systemic parasitology has grown remarkably, but translational research from bench to bedside needs to be improved. Newer molecular diagnostic techniques are essential for ophthalmic application. Many parasitic worms are developing resistance to available drugs, necessitating discovery of the next generation of anti-parasitic agents. The aim of this review is to understand the existing literature on ocular parasitosis, to highlight diagnostic and therapeutic advances, and to analyze the management algorithm on ocular parasitosis.

Biopsy pathology in uveitis.

Uveitis is fraught with speculations and suppositions with regard to its etiology, progress and prognosis. In several clinical scenarios what may be perceived as due to a systemic infection may actually not be so and the underlying etiology may be an autoimmune process. Investigations in uveitis are sometimes the key in identification and management. Invasive techniques could be of immense value in narrowing down the etiology and help in identifying the cause. This article updates one on the invasive techniques used in biopsy such as anterior chamber paracentesis, vitreous tap and diagnostic vitrectomy, iris and ciliary body biopsy, choroidal and retinochoroidal biopsy and fine needle aspiration biopsy (FNAB). In populations where certain infections are endemic, the clinical scenario does not always respect a known presentation and the use of biopsy is resorted to as a sure way of confirming the etiology. Biopsies have a role in diagnosis of several inflammatory and infectious conditions in the eye and are pivotal in diagnosis in several dilemmas such as intraocular tumors and in inflammations. Appropriate and timely use of biopsy in uveitis could enhance the diagnosis and provide insight into the etiology, thus enabling precise management.