A Comparative Study of Acute Invasive Fungal Sinusitis During the First and Second Waves of the COVID-19 Pandemic.

We aimed to compare the demography, clinical profile, histopathology, fungal culture, radiology, surgery performed, medical therapy and outcomes of patients with acute invasive fungal sinusitis seen during the first and second waves of the COVID-19 pandemic by retrospectively reviewing their case records. Of 238 patients, 43(18.1%) presented during the first wave and 195(81.9%) during the second wave. Patients seen during the first wave were older (p = 0.04) and more likely to have visual impairment (p = 0.004), frozen eye (p = 0.012), altered sensorium (p = 0.007) and stage 3 disease (p = 0.03). Those seen during the second wave were more often COVID-19 positive and had newly diagnosed diabetes mellitus (p = 0.04)and stage 1 disease (p = 0.03). Most patients had a positive culture for Rhizopus species during both waves. Histopathology showed broad aseptate hyphae in all patients but angioinvasion was seen more often during the first wave (p = 0.04). The majority of patients were treated with endoscopic+/- open debridement followed by intravenous amphotericin B and oral posaconazole. While the overall survival rate was similar (first wave 65.1%; second wave 79%; p = 0.106), mortality after discharge was greater during the first wave (11.6% vs 1.5%; p = 0.001). Mortality was higher in patients with stage 3 disease (p = 0.003). Significant differences in clinical presentation, histopathology, radiological stage of disease and post-discharge survival were noted between the two waves of the COVID-19 pandemic, the causes for which were multi-factorial.

Post-traumatic transocular retained foreign body in the infratemporal fossa: a near miss.

The infratemporal fossa is an uncommon site for lodgement of foreign bodies. Fast-moving projectiles and displaced teeth may get impacted and have been described in the literature. However, foreign body lodgement in the retromaxillary space after transorbital passage is rare. The trajectory of the foreign bodies in such cases is difficult to predict and may not be suspected in the absence of overt clinical features. The authors present a case of a wooden splinter lodged within the infratemporal fossa after the patient sustained a lid injury with an orbital floor fracture. Imaging was equivocal; hence, endoscopic surgical exploration was undertaken, revealing the foreign body. A high index of clinical suspicion and rapid intervention is needed since unsuspected foreign bodies may cause further visual, infective or neurovascular complications. Approaches should be tailored on a case-by-case basis.

Short intravenous amphotericin B followed by oral posaconazole using a simple, stratified treatment approach for diabetes or COVID-19-associated rhino-orbito-cerebral mucormycosis: a prospective cohort study.

OBJECTIVES: To evaluate the efficacy and safety of short-course intravenous amphotericin B followed by sustained release posaconazole tablets for diabetes or COVID-19-associated rhino-orbito-cerebral mucormycosis. METHODS: This prospective, pragmatic study included adults with diabetes or COVID-19-associated rhino-orbito-cerebral mucormycosis. Patients received short (7-14 days) or long (15-28 days) intravenous antifungal therapy (short intravenous antifungal treatment [SHIFT] or long intravenous antifungal treatment [LIFT], respectively) depending on the presence or absence of brain involvement. All patients received step-down posaconazole tablets, debridement, and glycemic control. The primary outcome was the treatment success at week 14, which was determined by assessing survival and the absence of disease progression through clinical evaluation and nasal endoscopy. Log-binomial regression analysis (risk ratio and 95% CI) was performed to assess factors associated with the primary outcome. RESULTS: Intravenous therapy was administered to 251 participants: SHIFT, 205 (median duration, 13 days); LIFT, 46 (median duration, 22 days). Treatment success at 3 months was 88% (217/248; 95% CI, 83-91%): SHIFT group, 93% (189/203; 89-96%); LIFT group, 62% (28/45; 47-76%). All-cause mortality was 12% (30/251): SHIFT group, 6% (13/205); LIFT group, 37% (17/46). Age (aRR [95% CI]: 1.02 [1.00-1.05]; p 0.027), diabetic ketoacidosis at presentation (2.32 [1.20-4.46]; p 0·012), glycated haemoglobin A1c (1.19 [1.03-1.39]; p 0.019), stroke (3.93 [1.94-7.95]; p 0·0001), and brain involvement (5.67 [3.05-10.54]; p < 0.0001) were independently associated with unsuccessful outcomes. DISCUSSION: Short intravenous amphotericin B with step-down posaconazole tablets should be further studied as primary treatment option for diabetes or COVID-19-associated mucormycosis in randomized controlled trials.

Chronic Granulomatous Invasive Fungal Sinusitis in Patients With Immunocompetence: A Review.

OBJECTIVE: We aimed to study the literature on chronic granulomatous invasive fungal sinusitis to elucidate the changing trends in the management of the disease. DATA SOURCES: Using specific keywords, we searched the PubMed, PubMed Central, and Scopus databases over the past 50 years, which yielded 938 articles in the English language. REVIEW METHODS: Scrutiny of 147 relevant articles revealed 15 homogenous case series (255 cases of histologically proven chronic granulomatous fungal sinusitis alone) and 8 heterogeneous case series (patients with other types of fungal sinusitis included), which were analyzed in detail (all with >5 cases each). CONCLUSIONS: The disease typically affected middle-aged adults with immunocompetence. Most reports were from Sudan, India, and Saudi Arabia. A slowly progressive orbital, cheek, or palatal mass with proptosis (88.2%) or sinonasal symptoms (39.2%) was typical. Ethmoid (57.2%) and maxillary (51.4%) sinuses were chiefly affected with intracranial extension in 35.1%. Aspergillus flavus (64%) was the most frequent isolate reported. Endoscopic excision (78.8%) followed by azole therapy was the preferred treatment in recent reports. Orbital exenteration and craniotomy were infrequently performed. Complete resolution or improvement was reported in 91.3% of patients. Mortality ranged from 5.9% to 22.2%. There is a trend in the literature toward less radical and disfiguring surgery and preferential use of azoles, with good outcomes even in advanced cases. IMPLICATIONS FOR PRACTICE: Chronic granulomatous fungal sinusitis should be diagnosed on the basis of well-defined histopathologic features. A combination of endoscopic sinus surgery and azole therapy usually yields good outcomes.

Conjunctival Relaxing Incisions with a Bare Bed: An Overlooked Privilege in Contracted Sockets.

INTRODUCTION: The aim of reconstruction of a contracted socket is to retain a satisfactory prosthesis. Simple procedures to modify the socket architecture as first line options could avoid multiple staged procedures, increased surgical time, harvesting tissues or use of allografts. The objective of this study was to evaluate the outcome of modifying the socket architecture by making conjunctival relaxing incisions leaving it bare to re-epithelialize and compare it to dermis-fat graft. MATERIALS AND METHODS: A retrospective review of all socket reconstruction surgeries in our hospital over a period of 10 years (July 2009 to June 2019) was done. The two procedures which were compared were dermis-fat graft (DFG) and conjunctival relaxing incisions (CRI) without a graft. In the latter, the split conjunctiva was left bare under a conformer and temporary tarsorrhaphy. The conjunctiva was allowed to re-epithelialize under cover of topical antibiotic and steroid. RESULTS: The patients included had a mean age of 24 years (n=8) in the DFG group and 36 years (n=10) in the CRI group. The most common cause of anophthalmic socket was enucleation for tumour and evisceration for trauma in the two groups, respectively. Six patients (75%) in the DFG group and six (60%) in the CRI group achieved good prosthesis retention (P = 0.51). None had post-operative infection. CONCLUSION: Transverse conjunctival relaxing incisions with tissue stretching can be a safe first line option to rehabilitate a contracted socket.

Risk factors associated with the mucormycosis epidemic during the COVID-19 pandemic.

This study was performed to assess the risk factors driving the epidemic of coronavirus disease 2019 (COVID-19)-associated mucormycosis (COVID-Mucor) in India that has accompanied the COVID-19 pandemic, particularly during the second wave. Risk factors were analysed among 164 participants: 132 COVID-Mucor (cases) and 32 non-COVID-Mucor (controls). Data from a prospective cohort study of mucormycosis over a period of 1 year were used. Diabetes mellitus remained a significant risk factor in both groups (97%), while uncontrolled diabetes mellitus (odds ratio (OR) 4.6; P = 0.026) and newly detected diabetes (OR 3.3; P = 0.018) were more common among the cases. Most patients with COVID-Mucor had mild COVID-19. Steroid use, often unwarranted, was highly associated with COVID-Mucor after adjusting for other risk factors (OR 28.4; P = 0.001). Serum ferritin was significantly higher (P = 0.041), while C-reactive protein was not, suggesting that alterations in iron metabolism may predispose to COVID-Mucor. Oxygen was used only in a small minority of patients with COVID-Mucor. The in-hospital mortality in both groups was low. In conclusion, the Indian COVID-Mucor epidemic has likely been driven by a convergence of interlinked risk factors: uncontrolled diabetes mellitus, unwarranted steroid use, and perhaps COVID-19 itself. Appropriate steroid use in patients with severe COVID-19 and screening and optimal control of hyperglycaemia can prevent COVID-Mucor.

Spectrum of Ocular Injuries and Visual Outcome Following Firework Injury to the Eye.

BACKGROUND: Ocular injury due to fireworks requires urgent ophthalmic assessment and management to preserve vision. METHODS: Spectrum of injury, type of intervention, visual outcome, and reasons for visual loss were assessed in consecutive patients presenting over 2 years with firework-related eye injury. The final visual outcome was recorded as best-corrected visual acuity. RESULTS: In the 96 patients (75 males) enrolled, 122 eyes were involved. Twenty-six patients had bilateral eye injury. The median (interquartile) age was 14 (8, 28.5) years. Injuries occurred during Diwali festival (59.4%) and funeral processions (20.8%); over half (53.8%) were bystanders. Injury was due to negligence (78%), device malfunction (12.5%), and attempts to reignite (5.2%) or recover failed device (4.2%). Presenting symptoms were redness (100%), pain (97%), watering (86%), and reduced vision (77%). Facial laceration, contusion, or hematoma occurred in 13 patients. The most frequent adnexal and ocular surface injuries were lid burns (57.3%), edema (44.2%), charred eyelashes (24.6%), and laceration (13.9%). Open-globe injury occurred in 8 eyes. Common anterior segment injuries were corneal epithelial defect (51.6%) and hyphema (20.5%). Posterior segment injuries included commotio retinae (13.1%) and Berlin's edema (7.4%). Surgical treatment was required in 15 eyes; 107 (88%) were managed conservatively. At study completion, of the 99 eyes evaluated, 21 had reduced visual acuity (<6/6) including 7 with monocular blindness. Factors associated with poor vision were open-globe injury (P < 0.001) and poor initial visual acuity (P = 0.05). CONCLUSIONS: Open-globe injury and poor visual acuity at presentation predict the final visual outcome. Monocular blindness following firecracker injury is common.

Orbital Metastasis of Cervical Carcinoma - Case Report and Review of Literature.

The orbit is a frequent site of metastasis, particularly from the breast, prostate gland and the lung. Carcinoma of the cervix metastasizing to the orbit is rare. We report a 27-year-old woman with Stage II B cervical cancer who presented with progressive painless protrusion of the left eye of one month duration associated with diplopia. Histology of the orbital mass was similar to that of the cervical cancer and reported as squamous cell carcinoma. She received palliative radiation to the left orbit 30 Gy in 10 fractions along with chemotherapy (Paclitaxel and Carboplatin). This resulted in regression of the proptosis. We review published literature of cases of carcinoma of the uterine cervix with metastasis to the orbit.

Incidence and risk factor evaluation of exposure keratopathy in critically ill patients: a cohort study.

PURPOSE: Recent emphasis on eye care in intensive care unit (ICU) patients has translated to eye assessment being part of routine care. In this setting, we determined the incidence, risk factors, and resolution time of exposure keratopathy. METHODS: In this prospective cohort study, 301 patients were examined within 24 hours of ICU admission and subsequently daily by an ophthalmologist till death or discharge. Eyelid position, conjunctival and corneal changes, treatment, and outcome data were collected. RESULTS: Admission diagnoses included febrile illnesses (35.2%) and respiratory failure (32.6%); 84.1% were ventilated. Forty-nine patients had exposure keratopathy (bilateral = 35, unilateral = 14) at admission; 35 patients developed new onset keratopathy (incidence 13.2%) 4.6 ± 2.6 days after ICU admission. In 67 patients, keratopathy was mild (punctate epithelial erosions). Macroepithelial defects (n = 9), stromal whitening with epithelial defect (n = 3), and stromal scar (n = 3) were infrequent. None developed microbial keratitis. On multivariate logistic regression analysis, eyelid position (odds ratio, 2.93; 95% confidence interval, 1.37-6.25), and ventilation duration (odds ratio, 1.11; 95% confidence interval, 1.04-1.19) were strongly associated with the development of keratopathy after ICU admission. Keratopathy resolved in 3.6 ± 4.5 days. CONCLUSIONS: Severe exposure keratopathy is infrequent in a protocolized ICU setting. Eyelid position and duration of ventilation are associated with exposure keratopathy.

Visual loss in Takayasu Arteritis - Look Beyond the Eye.

Patients with Takayasu arteritis often present with reduced vision related either to the disease per se or due to complications of therapy. We report a patient with Takayasu arteritis who developed acute onset bilateral visual loss 6wks following percutaneous revascularization of occluded aortic arch branches. No ocular cause for the visual loss was evident. The reason for visual loss in this patient was an extraocular cause. Ocular and extraocular causes of visual loss in Takayasu arteritis are discussed.

Idiopathic inflammatory orbital myositis presenting with vision loss.

We present a first case of 58-year-old man with vision loss in a biopsy-proven idiopathic inflammatory orbital tendon sparing myositis. Tests for thyroid autoantibodies were negative at the initial presentation and at 10-month follow-up period. The diagnosis was confirmed on histopathological examination and was also supported by avid sarcolemmal staining for MHC-1 and MHC-2.

Regression of takayasu retinopathy after revascularization of occluded branches of the aortic arch by percutaneous angioplasty.

PURPOSE: To present a patient with decreased vision because of Takayasu retinopathy who had improvement in vision and regression of retinopathy after percutaneous angioplasty of occluded aortic arch vessels. METHODS: Interventional case report. RESULTS: A 37-year-old woman with multiple cerebral infarcts and recurrent seizures was referred with painless progressive reduction in vision in the right eye of few months' duration and left eye for 2 years. Vision was 20/120 in the right eye and perception of light in the left eye. There was mild disk pallor in the right eye, optic atrophy in the left eye, and microaneursyms in both eyes. Angiographic findings were consistent with type I Takayasu arteritis. Angioplasty and stenting was performed initially to the right subclavian and common carotid arteries and to the left subclavian, and left internal carotid arteries 6 weeks later. There was improvement in vision to 20/80 and regression of Takayasu retinopathy in the right eye at 3 months post procedure that improved further to 20/50, 6 months post procedure. Vision, as expected, remained poor in the left eye despite revascularization. CONCLUSION: Restoration of flow in the aortic arch vessels may result in reversal of ischemic retinal changes in patients with Takayasu retinopathy.

Ocular manifestations of Takayasu arteritis: a cross-sectional study.

PURPOSE: To detail the spectrum of eye manifestations in Takayasu arteritis and factors predisposing to its development. METHODS: In this cross-sectional study, 61 patients with proven Takayasu arteritis who were identified during a 16-month period were evaluated for disease- and treatment-related eye manifestations. A fundus fluorescein angiography examination was performed where indicated and with the patients consent. RESULTS: The mean (±standard deviation) duration of illness before ophthalmic evaluation was 55 ± 69 months. Decreased vision was the most common ocular symptom (30%). Thirty-five patients underwent fundus fluorescein angiography examination. Takayasu retinopathy was seen in 9 (15%), ocular ischemic syndrome in 4 (7%), and hypertensive retinopathy in 10 (16%) patients. The most common treatment-related ocular complication was steroid-induced cataract (23%). Other manifestations included iris neovascularization (n = 3), anterior ischemic optic neuropathy (n = 2), steroid-induced glaucoma (n = 1), neovascular glaucoma (n = 1), and uveitis (n = 1). Those manifesting Takayasu retinopathy and ocular ischemic syndrome had significantly (P < 0.05) lower blood pressure in both upper limbs compared with patients not manifesting ischemic retinopathy. A significant (P < 0.03) proportion of patients with Takayasu retinopathy and ocular ischemic syndrome had a nonrecordable right upper limb blood pressure. CONCLUSION: Disease- and treatment-related ocular complications are not infrequent in Takayasu arteritis. Arteritis involving the aortic arch and its branches favors the development of ischemic ocular complications.

Hypoperfusive and hypertensive ocular manifestations in Takayasu arteritis.

Takayasu arteritis is a relatively rare inflammatory arteritis that can be associated with ocular manifestations. We report four patients with proven Takayasu arteritis; two patients manifested hypoperfusive ocular manifestations of ocular ischemic syndrome and anterior ischemic optic neuropathy whilst two others had exudative retinal detachment and papilledema as a result of severe hypertension. The ischemic ocular manifestations were a result of hypoperfusion of the ocular structures due to occlusive arteritis of the aortic arch and its branches. The exudative retinal detachment and papilledema were manifestations of severe hypertension due to renal arterial involvement. Patients with Takayasu arteritis should be referred for ophthalmic assessment and screening for hypoperfusive and hypertensive manifestations.

Oculocutaneous anthrax: detection and treatment.

Anthrax, a zoonotic disease that primarily affects herbivores, has received recent attention as a potential agent of bioterrorism. We report a patient who presented with a 4-day history of pain, watering and difficulty in opening the left upper and lower eyelids, and fever. Clinical examination revealed brawny nonpitting edema with serosanguinous discharge. The history of the death of his sheep 1 week prior to the illness provided the clue to the diagnosis. Although standard cultures of the blood and the serous fluid from the lesion were negative, probably as a result of prior treatment, the diagnosis of cutaneous anthrax was made by a polymerase chain reaction (PCR) test of the serous fluid. Serial photographs demonstrating resolution of the lesion with appropriate antibiotic therapy are presented.

Use of real-time telemedicine in the detection of diabetic macular oedema: a pilot study.

PURPOSE: The high prevalence of diabetic retinopathy (21-36%) and 2 yearly reviews recommended by the National Health and Medical Research Council for diabetics with no retinopathy creates a considerable burden for review in rural and regional Australia. Screening for diabetic retinopathy using telemedicine has significant implications. If effective, such a tool would have an impact on finance and resource allocation. The purpose of the study was to establish if telemedicine could distinguish clinically significant macular oedema (CSME) from eyes free of this form of disease. METHODS: A study population with representative examples of normal fundi and the different grades of retinopathy was chosen from existing records. The specificity and sensitivity of telemedicine diagnosis was compared with fundus photography and examination by an experienced ophthalmologist as a 'gold standard', in a blinded manner. Real-time telemedicine assessment was performed with live video and audio connections with the transmitting and receiving units set in different areas of the ophthalmology department. The transmission end consisted of a video camera mounted on a slit lamp and the receiving unit consisted of a 21'' LCD monitor. A video conference link was established using three ISDN lines capable of 128 kb per second transfer per line allowing for a total of 348 kb per second when utilizing all three lines for high resolution images. Fundus photographs were taken with a Zeiss FF 450 Plus Digital imaging system. RESULTS: For telemedicine, sensitivity was 38% (95% CI, 35-40%) and specificity was 95% (95% CI, 91-99%). For photography, sensitivity was 75% (95% CI, 71-79%) and specificity was 95% (95% CI, 91-99%). CONCLUSIONS: In this pilot study, sensitivity of detection of CSME by photography was considerably better than for live-link telemedicine. This study tends to confirm the continued superiority of examination of the patient by an experienced ophthalmologist as the best method of screening for CSME, a sight threatening form of diabetic retinopathy.

Limbal relaxing incisions versus on-axis incisions to reduce corneal astigmatism at the time of cataract surgery.

PURPOSE: To compare limbal relaxing incisions (LRIs) with placement of the corneal cataract incision on the steepest keratometric axis for the reduction of preexisting corneal astigmatism at the time of cataract surgery. SETTING: The Queen Elizabeth Hospital, Adelaide, South Australia, Australia. METHODS: In a prospective single center study, patients having 1.5 diopters (D) or more of keratometric astigmatism were randomly assigned to 2 surgical techniques: on-axis incisions (OAIs) consisting of a single clear corneal cataract incision centered on the steepest corneal meridian or LRIs consisting of 2 arcuate incisions straddling the steepest corneal meridian and a temporal clear corneal incision. Vector analysis of the target axis flattening effect was used to assess the efficacy of treatment. RESULTS: Seventy-one eyes of 71 patients were evaluated, 33 in the OAI group and 38 in the LRI group. Six weeks postoperatively, the flattening effect was 0.41 D (median and interquartile range 0.15 to 0.78 D) in the OAI group and 1.21 D (range 0.43 to 2.25 D) in the LRI group (P = .002). After 6 months, the flattening effect was 0.35 D (range 0.00 to 0.96 D) and 1.10 D (range 0.25 to 1.79 D), respectively (P = .004). CONCLUSION: The amount of astigmatism reduction achieved at the intended meridian was significantly more favorable with the LRI technique, which remained consistent throughout the follow-up period.

Fluorescein angiographic monitoring of corneal vascularization in lipid keratopathy.

The use of digital fluorescein corneal angiography to assist argon laser photocoagulation is reported. Photocoagulation was performed on the vascular supply of lipid keratopathy in the left eye of a 44-year-old woman.