Risk factors and clinical presentation of rhino-orbital mucormycosis: Lesson learnt during Covid pandemic.

Aim: To analyze the potential predisposing factors and clinical presentation of mucormycosis in patients with COVID-19. Material and Methods: Medical records of 141 patients with COVID-19-associated mucormycosis (CAM) treated at a tertiary care center in Bihar were reviewed. The predisposing factors, clinical features, and imaging findings of mucormycosis were analyzed. Results: The median age was 48 years (IQR, 43-60). A total of 58 patients developed concurrent CAM and 83 post-CAM. The median interval between COVID-19 and onset of CAM symptoms was 15 days (IQR, 9-16). A total of 80 patients received at-home treatment for COVID-19, and 73 had mild-to-moderate disease. While 61 patients received in-hospital treatment, 57 had severe disease. At presentation, 131 patients had hyperglycemia: 64 type 2 diabetes mellitus (DM) and 67 new-onset DM. The history of glucocorticoid use for COVID-19 was present in 125 patients; 47% were administered at home without monitoring plasma glucose. The common presenting features were toothache, periocular or facial pain, and edema. Rhino-orbital mucormycosis was the most common. Imaging revealed rhinosinusitis in all patients, including pansinusitis (68%), pterygopalatine fossa involvement (21%), cavernous sinus thrombosis (38%), brain abscess (8%), and infarct (4%). All patients received intravenous liposomal amphotericin B, and surgical debridement was performed in 113. Conclusion: COVID-19 patients with hyperglycemia are at risk of developing CAM, irrespective of the severity. Timely recognition of symptoms and prompt initiation of therapy by primary healthcare physicians are imperative for enhancing outcomes. Additionally, glucocorticoid overuse should be avoided, and close monitoring for hyperglycemia development is warranted.

Bilateral acute macular neuroretinopathy associated with COVID-19 infection presenting with central scotoma.

Purpose: To report a case of bilateral acute macular neuroretinopathy (AMN) associated with COVID-19 infection presenting with central scotoma. Observation: A 26-year-old female presented with a chief complaint of bilateral central scotomas for the last seven days. She had a history of fever over the past ten days, and RT-PCR test for COVID-19 was positive on the second day of fever. She had been vaccinated against COVID-19 eight months prior. Her best corrected visual acuity was 6/6 in both eyes on the Snellen chart. Dilated fundus evaluation revealed subtle bilateral perifoveal grey macular lesions. Optical coherence tomography (OCT) demonstrated focal hyperreflectivity at the level of the outer nuclear and plexiform layer consistent with bilateral AMN. Near-infrared reflectance (NIR) and red-free (RF) imaging showed large, confluent hyporeflective lesions in the right eye and discrete petaloid lesions with apices pointing toward the fovea in the left eye. OCT angiography (OCTA) revealed decreased flow signal at the level of the deep capillary plexus (DCP) and choriocapillaris (CC) in both eyes. Automated visual field testing (Humprey Field Analyzer (HFA) 24-2) revealed bilateral central scotoma with depression of adjacent points. After two weeks, the patient had depressed visual fields on HFA 10-2. At two months of final follow-up, OCT macula, NIR and RF images revealed resolving AMN lesions in both eyes. OCTA showed an increase in perfusion at the level of the DCP. There was a decrease in scotoma density on HFA 10-2, suggestive of resolving AMN. Conclusion and importance: AMN with central scotoma as presenting feature of COVID-19 is rare. Fundus findings may be very subtle in AMN, but NIR and RF imaging delineate the lesions well. OCT, NIR imaging, OCTA and HFA 10-2 can be used to assess the clinical course of AMN.

Impact of positive airway pressure therapy on intraocular pressure in obstructive sleep apnea: A systematic review.

BACKGROUND: Positive airway pressure (PAP) therapy has been reported to have variable effect on intraocular pressure (IOP) in patients with obstructive sleep apnea (OSA) . The objective of this review is to present a qualitative assessment of available literature on impact of PAP on IOP in patients of OSA.Method: Online databases were searched for relevant articles up to September 2023. It included randomized control trial (RCT), prospective observational study, case control study, cross-sectional study, published abstract having relevant information. The comparator group consisted of OSA patients not receiving the PAP therapy or the pre-PAP IOP. Studies reporting change in IOP immediately after PAP use, at 1 month and at 1 year of PAP use were included. For quality assessment Cochrane Risk of Bias tool version 2 and NIH study quality assessment tool for Before-After (Pre-Post) Studies with No Control Group was used.Result: In this systematic review of ten clinical studies with 191 patients of OSA, use of continuous positive airway pressure (CPAP) therapy led to an immediate increase in IOP but it was not significantly different from non-CPAP users. One month and 1 year of CPAP use led to a significant increase in IOP from the baseline value. CONCLUSION: The available albeit limited evidence suggests that CPAP use, particularly at higher pressures, is linked to an elevation in IOP. However, high quality evidence from well-designed RCTs is needed to confirm or refute this findings.

Restoring the Ocular Integrity of Perforated Corneal Ulcer Using Living Surgical Donor Tissues Derived From Keratoplasty in the COVID-19 Pandemic.

The coronavirus disease 2019 (COVID-19) caused an unprecedented crisis for corneal surgeons who were forced to strategize for an acute shortage of tissues. Here, we report the initial clinical outcomes of utilizing host corneal buttons derived from optical penetrating keratoplasties of pseudophakic bullous keratoplasty (PBK) patients. Two patients presented to our department with a perforated fungal corneal ulcer in one eye during the COVID-19 pandemic. One eye of each of the patients was operated on with non-vascularized host cut tissues preserved in glycerin. The tissues were secured using 10-0 nylon sutures. Good anatomical integrity was achieved in both eyes. An optical penetrating keratoplasty (PK) was done in both eyes after one year for visual rehabilitation, with a final visual acuity of 20/120 and 20/80, respectively, at six months. In conclusion, therapeutic PK using host tissues obtained from the recipients of optical PK is a safe and effective option to restore ocular integrity during a shortage of fresh or glycerol-preserved corneas. However, optical PK is required for the final visual rehabilitation.

Limbal stem cell deficiency: Demography, aetiology, and clinical presentation in Eastern India.

Aims: To determine demographic details, clinical profile, and underlying causes of limbal stem cell deficiency. Settings and Design: Descriptive cross-sectional study. Methods and Material: Patients visiting tertiary referral hospitals between January 2019 and December 2022 who satisfy the criteria for labeling limbal stem cell deficiency (LSCD) were enrolled. Parameters such as age, gender, region, duration, aetiology, and clinical features were noted. Descriptive statistics was applied. The student t-test was used. Results: A total of 731 eyes of 489 patients with LSCD were included in our study, with age ranging from 5 to 85 years (35.0 ± 19.4 years). The most common presenting complaints were a decrease in vision 473 (96.7%), most of them 342 (69.7%) are having history of gradual progression (>3 months), and 245 (50.1%) have bilateral involvement of eyes. Average corneal clarity was found to be grade 1.6 ± 1.2 and average corneal superficial neovascularization was found to be 7.9 ± 4.3 quadrants. Clinically, we found LSCD of about up to 90° in 57 eyes, 90 to 180° in 71 eyes, 215 eyes with 180 to 270°, and the rest of 388 eyes were having more than 270° of LSCD involvement. Out of 489 patients, 142 (29.0%) patients were of chemical injury, 125 (25.6%) patients were of Steven Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN), followed by 61 (12.5%) patients of vernal keratoconjunctivitis (VKC). Conclusions: The majority of patients were young males presented with more than 270° LSCD and vision <2/60. In our study, chemical injury was most common in unilateral LSCD and SJS/TEN in bilateral LSCD.

OPTIC DISK PIT STUFFING-TO DO OR NOT TO DO.

PURPOSE: Optic disk pit (ODP) is a subset of spectrum of congenital cavitary anomalies. Optic disk pit maculopathy causes progressive visual deterioration and is addressed with pars plana vitrectomy (PPV) with or without ODP stuffing. PATIENT AND METHODS: We report a case of progressive ODP maculopathy who was taken up for 23-G 3-port PPV, with complete vitreous removal and stuffing of the ODP with autologous sclera and sequential analysis of change in the retinal nerve fiber layer (RNFL) thickness. RESULTS: Spectral-domain optical coherence tomography RNFL analysis at 1 and 12 months follow-up postoperatively showed total RNFL thickness decrease from 130 µm to 103 µm respectively. Hemiquadrant analysis showed slight reduction of superior RNFL thickness from 142 µm to 139 µm. However, in the inferior hemiquadrant, the reduction in mean RNFL thickness seems to be significant from 133 µm to 100 µm at 1 and 12 months respectively. Sector-wise analysis of the RNFL thickness showed maximum reduction in the inferotemporal quadrant and other sectors seemed to be relatively preserved corresponding to the area of scleral stuffing. CONCLUSION: Retrospective or prospective analysis of RNFL health of patients undergoing surgery for ODP-M with stuffing needs to evaluated.

Epidemiological and microbiological profiles of microbial keratitis in a tertiary eye center in Eastern India (Bihar).

Purpose: To determine the demography, risk factors, and causative organisms of microbial keratitis (MK) in Bihar, an eastern state of India. Design: Retrospective study. Methods: We reviewed the demographic, clinical, and microbiological data of 2303 patients with MK (non-viral) presenting between January 2019 and December 2022. Results: This study revealed a predominance of males (65.0%) compared to females (34.9%), with a mean age of 48.4 ± 16.5 years. The majority of patients (63.1%) presented after 2 weeks from the onset of symptoms. The most common risk factor observed was corneal injury (58.1%), followed by ocular surface diseases (13.6%) and diabetes mellitus (13.3%). The majority of patients (73.16%) were involved in agriculture. Prior to presentation, almost all patients (92%) had received topical antibiotics. Unsupervised use of topical corticosteroids was observed in 29.2% of the patients for the median duration of 3 days (odds ratio, 0.17). At presentation, the median size of corneal ulcers was 5 mm, the best-corrected visual acuity was less than 20/400 in 51.4% of patients, and corneal perforation was in 14% of patients. The smear and culture positivity rate were 75.4% and 47.9%, respectively. The common causative organism was fungus (48.8%), followed by bacteria (17.4%). Aspergillus spp. and Staphylococcus spp. were the most commonly identified organisms; a quarter of the patients (24.5%) remained unidentified. All bacteria showed good sensitivity to vancomycin. Conclusion: MK is a significant cause of ocular morbidity in Bihar. The knowledge of epidemiology, risk factors, and microbiological profiles of MK can provide a valuable approach to disease prevention, diagnosis, and management.

Role of corneal collagen cross-linking in bullous keratopathy: A systematic review.

Corneal cross-linking (CXL), a corneal strengthening procedure, is known to alter anterior stroma swelling behavior and is one of the treatment modalities of bullous keratopathy (BK). There are multiple studies published on the role of CXL in the treatment of BK. These articles had heterogeneous study population, different protocols used, and variable conclusions. This systematic review aimed to determine the role of CXL in the treatment of BK. The primary outcomes considered were changes in central corneal thickness (CCT) after 1, 3, and 6 months of CXL. The secondary outcome measures were changes in visual acuity, corneal clarity, subjective symptoms, and complications after CXL. We included randomized control trials (RCTs), observational and interventional studies, and case series with reports of more than 10 cases in this review. In RCTs, the mean pre-CXL CCT (794.0 ± 178.5 µm) in the intervention group (n = 37), decreased at 1 month (750.9 ± 154.3 µm) followed by a subsequent increase, but this difference was not significant during the 6-month follow-up (P- value 0.28, 0.82, and 0.82 at 1, 3, and 6 months, respectively). In noncomparative clinical studies (n = 188), the mean pre-CXL CCT (794.0 ± 178.5 µm) decreased at 1 month (710.9 ± 127.2 µm, P < 0.0001). Seven of the 11 articles included in the review reported no significant improvement in vision with CXL. The initial improvement in corneal clarity and clinical symptoms was not sustained. Current evidence suggests that CXL has short-term efficacy in the treatment of BK. More RCTs with high-quality evidence are needed.

Comparative evaluation of effectiveness of twenty versus fifty percent autologous serum eye drops in treatment of dry eye.

Purpose: The objective of the study was to compare the efficacy and safety of two concentration of autologous serum (AS) 20% vs 50% in recalcitrant moderate-to-severe dry eye patients. Methods: A double-blind prospective, interventional, and randomized study was done on 44 patients (80 eyes) clinically diagnosed with moderate-to-severe dry eye disease (DED) that was refractory to conventional treatment, and all patients were treated with AS20% or AS50% for 12 weeks. We documented Ocular Surface Disease Index (OSDI), tear film breakup time (TBUT), OXFORD corneal staining score (OSS), and Schirmer test (ST) at baseline, 2,4,8, and 12 weeks. These parameters were compared in both groups and between the groups by using Student's t-test. The study included 11 males and 33 females. Results: Out of 80 eyes, 33 eyes had moderate and 47 had severe DED. The age of patients in AS20% was 44.73 ± 14.37 years, and in AS50% was 46.41 ± 14.47 years. The most common etiology associated with DED was secondary Sjogren syndrome. In moderate DED, both the groups showed significant improvement in both subjective and objective parameters. But in severe DED, the AS20% group failed to show any significant improvement objectively, though subjective improvement was present. Conclusion: In refractory severe DED patients, AS50% is better option for treatment and in moderate DED both concentrations of autologous serum are effective.

Ocular manifestations of common pulmonary diseases: a narrative review.

Several pulmonary disorders can cause ocular involvement. Understanding these manifestations is critical for early diagnosis and treatment. Hence, we set out to examine the most common ocular manifestations of asthma, chronic obstructive pulmonary disease (COPD), sarcoidosis, obstructive sleep apnea (OSA), and lung cancer. Allergic keratoconjunctivitis and dry eye are two ocular manifestations of bronchial asthma. The inhaled corticosteroids used to treat asthma can cause cataract formation. COPD is associated with ocular microvascular changes as a result of chronic hypoxia and systemic inflammation spillover into the eyes. Its clinical significance, however, is unknown. Ocular involvement is common in sarcoidosis, occurring in 20% of cases of pulmonary sarcoidosis. It can affect nearly any anatomical structure of the eye. Obstructive sleep apnea has been linked to floppy eye syndrome, glaucoma, non-arteritic anterior ischemic optic neuropathy, keratoconus, retinal vein occlusion, and central serous retinopathy, according to research. However, while an association has been established, causality has yet to be established. The effect of positive airway pressure (PAP) therapy used to treat OSA on the aforementioned ocular conditions is unknown. PAP therapy can cause eye irritation and dryness. Lung cancer can affect the eyes through direct nerve invasion, ocular metastasis, or as part of a paraneoplastic syndrome. The goal of this narrative review is to raise awareness about the link between ocular and pulmonary disorders in order to aid in the early detection and treatment of these conditions.

Single Low-dose Suprachoroidal Triamcinolone Acetonide Injection in Macular Edema Secondary to Noninfectious Posterior Uveitis.

PURPOSE: The purpose was to study the anatomical and functional outcome following single low-dose suprachoroidal triamcinolone acetonide (LD-SCTA) (2 mg) injection in noninfectious posterior uveitis. METHODS: Eleven patients with macular edema (ME) more than 280 µ secondary to noninfectious uveitis were included in the study. A single LD-SCTA (0.5 ml) injection was performed in the study eye with the help of a novel suprachoroidal microneedle (Pricon, Iscon Surgicals, Jodhpur, Rajasthan, India). The study parameters were noted at 4 and 12 weeks post LD-SCTA injection. RESULTS: Ten of 11 patients had a significant decrease in central macular thickness (CMT). The mean CMT measurement at baseline was 513.6 ± 191.73 µm for the 10 patients who responded to the treatment, which reduced significantly to 265.1 ± 34.72 µm (P < 0.003) and 260.6 ± 34.72 µm (P < 0.002) at 4 and 12 weeks, respectively. The mean best-corrected visual acuity (BCVA) at baseline was 0.84 ± 0.41 logMAR unit which improved to 0.52 ± 0.33 (P < 0.001) and 0.25 ± 0.22 (P < 0.000) at weeks 4 and 12, respectively. The mean intraocular pressure at baseline recorded was 16.36 ± 2.97 mmHg, 19.45 ± 4.80 mmHg (P = 0.06) at 4 weeks, and 17.27 ± 2.53 mmHg (P = 0.35) at 12 weeks. One eye which did not respond to LD-SCTA was a case of recurrent Vogt-Koyanagi-Harada disease. CONCLUSION: Single LD-SCTA injection is efficacious in reducing CMT in ME, improving BCVA, and controlling the inflammation in noninfectious posterior uveitis. LD-SCTA can be used as a first-line therapy in noninfectious uveitis over other routes of steroid administration with a favorable outcome and safety profile.

Clinical outcome and course of Tenon's patch graft in corneal perforation and descemetocele.

Purpose: To assess the efficacy and clinical outcome of Tenon's patch graft (TPG) in corneal perforation and descemetocele. Methods: In this retrospective study, medical records of 83 patients (85 eyes) who underwent TPG for corneal perforation (58, 68%) or descemetocele (27, 32%) between July 2018 and October 2021 were reviewed. Clinical examination and anterior segment optical coherence tomography (AS-OCT) were performed on every follow-up visit. Anatomical success was considered as the restoration of the structural integrity with the formation of scar and anterior chamber (AC). Results: The mean size of the corneal lesions (corneal perforation or descemetocele) was 4.20 ± 1.01 mm. The mean follow-up period was 9.2 ± 5.48 months. The common underlying etiologies were infectious keratitis in 48% and autoimmune disorders in 35% of cases. TPG successfully restored the globe integrity in 74 (87%) eyes (83% in perforation and 96% in descemetocele). Anatomical failure occurred in 11 eyes (13%). The failures were due to graft dehiscence (8 eyes), graft ectasia (1 eye), and scarring with flat AC (2 eyes). The median time to epithelialization and scar formation were 3 and 15 weeks, respectively. Logistic regression analysis showed few predictors for a successful outcome: descemetoceles, noninfective causes, viral keratitis in infectious etiology, and paracentral or peripheral lesions. Conclusion: TPG can be considered an effective and inexpensive treatment for restoring the structural integrity in the eyes with perforations and descemetoceles, particularly when the donor tissue is unavailable. AS-OCT is a valuable noninvasive tool for monitoring the graft status.

Corneal endothelial protection during manual small-incision cataract surgery: A narrative review.

Cataract causes bilateral blindness in 20 million people globally, the vast majority of whom live in developing countries. Manual small-incision cataract surgery (MSICS) has emerged as an efficient and economical alternative to phacoemulsification, giving comparable results in terms of final visual gain. One of the important determinants of postoperative visual gain is the status of the corneal endothelium. Multiple factors such as corneal distortion, irrigation solution turbulence, mechanical trauma by instruments, nuclear fragments, intraocular lens contact, and free oxygen radicals, all have been implicated in causing corneal damage during cataract surgery. MSICS with posterior chamber intraocular lens implantation has been reported to cause an endothelial cell loss of 15.83%, which is comparable with other modes of cataract surgery like extracapsular cataract extraction and phacoemulsification. Thorough preoperative assessment of endothelial status and taking necessary steps for endothelial protection during surgery can decrease the endothelial cell loss and overall burden of pseudophakic bullous keratopathy. In addition to surgical techniques, the type of irrigating solutions, ocular viscoelastic devices, intracameral dyes, and drugs all affect the endothelial cell status. This review presents a summary of available literature on the protection of endothelial cells during different steps of MSICS. This is especially relevant for developing countries where large-scale MSICS cataract surgeries are performed to decrease the cataract blindness burden.

Outcomes of Transcutaneous Retrobulbar Amphotericin B in Rhino-Orbital-Cerebral Mucormycosis Among Patients Recovering From COVID-19: A Preliminary Experience.

Background In this study, we aimed to assess the outcomes of transcutaneous retrobulbar injection of amphotericin B (TRAMB) in rhino-orbital-cerebral mucormycosis (ROCM) among patients recovering from coronavirus disease 2019 (COVID-19). Methodology This retrospective study was conducted at a tertiary care center in eastern India from May 29th to July 31st, 2021, and included post-COVID-19 patients admitted with stage 3 and 4a ROCM who underwent TRAMB. The details of the ophthalmic examination, laboratory investigations, and radiological examination were retrieved from patients records. Patients were given TRAMB (3.5 mg/mL) on alternate days till they underwent debulking surgery and resumed from the second postoperative day alternatively till the patients showed clinical stabilization or improvement. Results In total, 45 eyes of 41 patients were included in the study. The median number of injections given was six (minimum = 3; maximum = 10). Following was the distribution of number of injection needed in each eye: eight eyes (three injections), six eyes (four injections), seven eyes (five injections), three eyes (six injections), eight eyes (seven injections), 11 eyes (eight injections), and one eye had received nine and ten injections each. Overall, 21/32 (65.62%) eyes had improvement in proptosis whereas 9/32 (28.12%) had improvement in ptosis. Six patients had improvement in extraocular movement. In total, 25 eyes had no improvement whereas seven eyes had improvement in vision. Four eyes underwent exenteration. All nine patients with limited orbital disease had good improvement with fewer injections (median = 4). None of the patients undergoing TRAMB had an intracranial extension of disease. Moreover, 8.88% (4/45) of the eyes had post-TRAMB transient inflammation which resolved without any intervention. Finally, 3/41 of the patients died. Conclusions TRAMB can be considered as an useful therapeutic adjunct in managing ROCM. Further, it can halt the progression of the disease while awaiting definitive surgical intervention.

Management of acute corneal hydrops with compression sutures and air tamponade.

Background: Acute corneal hydrops is a vision threatening complication of corneal ectasia like keratoconus, keratoconus, keratoglobus, Pellucid marginal degeneration, Terrien's marginal degeneration and post refractive surgery keratectasia. The associated risk factors for development of corneal hydrops (CH) are early onset of keratoconus, microtrauma associated with contact lens use, eye rubbing, allergic conjunctivitis, atopy, and Down's syndrome. With the conservative approach of management of CH, it takes longer time (in months) for corneal oedema to get resolved and there is development of vascularization and scarring. This video presents the simple technique of using compression sutures along with pneumodescemetopexy by intracameral air injection for management of CH. It led to rapid resolution of corneal oedema. It is a simple technique, with no need of special gases like C3F8 or SF6 and can be easily performed at a very basic set up. Purpose: To highlight the efficacy of simple technique of applying compression sutures and air tamponade in management of CH and to demonstrate the efficacy of anterior segment OCT in diagnosis and to assess the prognosis of a case of CH. Synopsis: A 9-year-old boy presented with CH, with anterior segment OCT showing torn descemet's membrane and fluid pockets in corneal stroma. Four full-thickness compression sutures were applied and intracameral sterile air was used for pneumodescetopexy. The serial post operative clinical and OCT picture showed rapid resolution of corneal oedema. Highlights: This video highlights the use of OCT imaging in the diagnosis of CH and full-thickness compression sutures as the safe and effective technique in the management of acute CH. Video link: https://youtu.be/54C3hJB_WTM.

Clinico-epidemiologic characteristics of optic neuritis in a tertiary eye centre in Eastern India based on the status of serum aquaporin-4 antibody.

PURPOSE: To elucidate the clinico-epidemiologic characteristics of optic neuritis based on the status of serum aquaporin-4 antibody (AQP4-Ab) in patients with optic neuritis (ON). METHODS: Medical records of 106 patients with ON and a follow-up of 3 years were reviewed. For each patient, the following data were extracted: medical history, findings of the ocular examination, brain, orbital or spinal MRI, and serological tests for AQP4. The ON was classified as typical or atypical based on disc examination and improvement in vision after intravenous methylprednisolone (IVMP). The clinical findings (typical or atypical), disease course, and outcomes were analyzed according to the serostatus of the ON. RESULTS: 10 patients ((9.4%) were seropositive for AQP4-Ab; all had atypical ON. 96 patients (91%) were seronegative for AQP4-Ab: 36 atypical ON and 60 typical ON. Profound visual impairment at presentation was seen in all patients. However, at the end of the study period, seropositive and seronegative atypical ON had poor visual outcomes as compared to seronegative typical ON (P = 0.002). Five seropositive and four seronegative patients with atypical ON developed transverse myelitis. Bilateral disease with relapse was more in seropositive patients (80%); however, seronegative with atypical ON also had bilateral presentation and relapse in 42% and 41%, respectively. CONCLUSION: AQP4-Ab seropositive patients mostly present with atypical features such as bilateral recurrent ON, poor visual outcome, and increased incidence of transverse myelitis. However, atypical clinical features can also be seen in seronegative ON with a poor visual outcome and a recalcitrant course.

Trends of rhino-orbito-cerebral mucormycosis in COVID-19 patients: An observational study.

Background and Aim: Mucormycosis is a potentially lethal but rare fungal infection that is rapidly progressive. Rhino-orbito-cerebral mucormycosis (ROCM) was the predominant presentation of COVID-19-associated mucormycosis (CAM). Hence, the present study aimed to assess the oral manifestations in CAM patients admitted to the Indira Gandhi Institute of Medical Sciences-A Tertiary Health Care Center. Materials and Methods: This study was conducted on hospitalized patients admitted to our tertiary health care center during the second wave of the COVID-19 pandemic. A total of 54 patients were included in the study and were further evaluated for oral manifestations. Detailed history, clinical examination, and surgical exploration was done for all the subjects. All cases were confirmed by MRI and histopathology. Results: Data collected was subjected to descriptive and inferential statistical analyses. Patients with oral manifestations were mostly in the age range of ≤50 years which was 56.7% (n = 17). Male patients 56.7% were affected more as compared to female patients and most of the patients in our study were from rural areas 56.7%. RBS [Mean ± standard deviation (SD)] was 304.60 ± 100.073. On intra-oral examination 96.7% had a gingival and palatal abscess, 63.3% had tooth mobility, and palatal ulcer/perforation was seen among 56.7% of the patients. Conclusion: The second wave of the COVID-19 pandemic had also created an alarming situation in India and worldwide. Mucormycosis had come as a sudden storm which has created an emergency situation in our hospital and for dental practitioners also. This was also an alarming situation for a dental practitioner for evaluating early signs and symptoms, especially in high-risk patients and decreasing mortality.

Status of Rho kinase inhibitors in glaucoma therapeutics-an overview.

Medical management remains the cornerstone of glaucoma management despite advances in the surgical or laser procedures. After a leap of almost two decades of the advent of prostaglandin analogues, recently a new class of drug, Rho kinase (ROCK) inhibitors, has come to limelight because of their varied therapeutic potential in different clinical conditions of eye, especially glaucoma. Their efficacy of lowering intraocular pressure (IOP) by virtue of an entirely different mechanism of decreasing outflow resistance has ignited a series of clinical trials evaluating their potential as monotherapy or as adjunct to existing antiglaucoma medications, and three of them ripasudil, netarsudil and roclatan have even been approved for clinical use in the recent past. There are evidences suggesting their beneficial effects in glaucoma patients even via non-IOP-dependent mechanisms like neuroprotection by improving blood flow to the optic nerve and increasing ganglion cell survival. They can even act as antifibrotic agents and reduce bleb scarring after glaucoma surgery. Hence, their effective role in glaucomatous optic neuropathy is multifaceted primary being improved drainage through the conventional pathway. On the other hand, certain local adverse effects like conjunctival hyperaemia have been reported in substantial proportion of patients, while some others like blepharitis, subconjunctival haemorrhages and cornea verticillata constitute less common side effects. The purpose of this review is to summarize the discovery, evolution and recent update of clinical trials on Rho kinase inhibitors as antiglaucoma medicine and to delineate their role in existing management protocol.

Haemlacria: A mini case series of a rare condition.

Haemlacria is a rare condition which is not widely mentioned in literature. In this mini case series, we describe two cases with this presentation. Both the patients were women with unilateral presentation of haemlacria in the right eye. Case one was diagnosed with photosensitivity, while case two was assumed to be due to an undiagnosed systemic illness which led to her mortality. Careful history, systemic examination, slit- lamp biomicroscopy, fundus examination, relevant haematological tests like coagulation profile, liver function test along with nasolacrimal duct probing with syringing and appropriate imaging may be needed to arrive at a diagno sis. Though many cases are idiopathic yet this can be a sign of an underlying life-threatening disease.

Keratitis occurring in patients treated with miltefosine for post-kala-azar dermal leishmaniasis.

AIM: To describe the characteristic clinical features and management of keratitis in the patients receiving miltefosine for post-kala-azar dermal leishmaniasis (PKDL). METHODS: The medical records of five patients with PKDL who presented with keratitis were reviewed retrospectively from April 2018 to December 2019. The evaluation included a thorough medical history including details on drugs used, particularly miltefosine. The drug causality assessment was also performed. The clinical and microbiological characteristics of keratitis were noted. RESULTS: The ocular symptoms included pain, redness, watering, photophobia and diminution of vision. Slit-lamp biomicroscopy revealed peripheral, paralimbal, ring-shaped, full-thickness stromal infiltration resulting in ulcerative keratitis in all cases. Two patients had unilateral keratitis, while three had bilateral keratitis. All five patients received miltefosine for an average period of 48 days before the onset of keratitis. The corrected distance visual acuity at presentation ranged from hand movement to 20/125. The causality assessment revealed a 'probable' association between the adverse drug reaction and miltefosine in all patients. Discontinuation of miltefosine and initiation of corticosteroid therapy resulted in resolution of keratitis in all cases. The unilateral keratitis treated with topical corticosteroids had improved outcomes, but poor outcomes were found in the bilateral keratitis. CONCLUSION: These observations indicate that prolonged use of miltefosine might cause keratitis that resembles infectious keratitis. Early diagnosis with discontinuation of the drug and initiation of corticosteroid therapy are the key to successful management.