Is mucormycosis the end? A comprehensive management of orbit in COVID associated rhino-orbital-cerebral mucormycosis: preserving the salvageable.

BACKGROUND: Rhino-orbital-cerebral mucor mycosis (ROCM) is a relatively rare opportunistic infection caused by the Mucorales species. While ROCM suggests involvement of the paranasal sinuses, orbit and brain ROM (rhino-orbital-Mucormycosis) stands for the fungal invasion in sinuses and orbit sans cerebral involvement. In India with the outbreak of the second COVID wave and the delta variant of the virus, there has been a steep increase in this opportunistic fulminant fungal infection, named COVID-associated Mucor mycosis (CAM). The most critical question in orbital management is when to go ahead with an exenteration. Our study aims to design a pertinent minimal invasive surgical protocol for surgeons to manage such cases based on our surgical experience and mitigate the need for exenteration and save the eyes wherever possible. METHODS: The study is a retrospective analysis of patients of ROM with and without brain involvement, who underwent minimal surgical management between March 2021 to March 2022 along with their follow-up. RESULTS: There were 184 eyes of 148 patients diagnosed with CAM. The mean age was 51.7 years with a male predominance of 103 (70%). All patients developed ROM following the COVID-19 infection and the duration between diagnosis of COVID-19 and ROM was 36 ± 23 days. 18 cases (12%) were bilateral. 76 eyes (41%) had no vision at the presentation. Imaging revealed paranasal sinus involvement (100%), orbital apex involvement (61%), cavernous sinus involvement (53%), and central nervous system (CNS) involvement (47%). All the patients (100%) were treated with systemic Liposomal amphotericin-B and sinus debridement. Endoscopic debridement of the orbital disease was performed in 45 (30.4%) cases, 15(8.1%) eyes underwent exenteration and were later rehabilitated with a customized ocular prosthesis, 103 (56%) eyes underwent transcutaneous retrobulbar amphotericin-B. At a mean follow-up of 13.1 months; the complete resolution was seen in 25 (17%) cases, the residual stable lesion was seen in 77(52%) of the cases and new lesions were developed in 13(9%) of the cases. Mortality was seen in 33 (22%) patients and all of them had CNS involvement. CONCLUSIONS: Systemic and protocol-based management can save the life and salvage the eyes.

Impact of COVID-19 nationwide lockdown on retinoblastoma treatment and outcome: A study of 476 eyes of 326 children.

Purpose: The novel coronavirus SARS-CoV-2 (COVID-19) and the resultant nationwide lockdown and travel restrictions led to difficulty in providing timely and regular treatment to patients with childhood cancers such as retinoblastoma. This study is aimed at assessing the demography, clinical presentation, treatment strategies, and outcome of treatment defaulters due to the lockdown. Methods: Cross-sectional, observational study of retinoblastoma patients at a tertiary care ocular oncology center during the first wave of COVID-19 and the resulting nationwide lockdown. Results: Of the 476 eyes of 326 patients undergoing active management with a median age of 57 months (range: 4-214 months), 205 (63%) patients returned for follow-up after a mean delay of 45.8 ± 24.3 weeks (range: 8-80 weeks) and 121 (37%) were defaulters according to the data analyzed till June 30, 2021. Distance of residence was ≥1000 km for 148 patients (46%). In terms of need for active treatment, the number of emergent cases was 2 (<1%), 11 (3%) were urgent, and 313 (96%) were semi-urgent. International classification groups D (n = 107 eyes, 23%) and E (n = 173 eyes, 36%) were in majority, and 13 eyes (4%) and 4 eyes (1%) were at stages 3 and 4, respectively. Prior to lockdown, 86 eyes (18%) had active tumor, which remained unchanged (n = 26, 30%) or worsened (n = 49, 60%) after failure to follow-up. Vision (47%), eye (92%), and life salvage (98%) were achieved by individualized protocol-based management after the patients returned for further management. Five children succumbed to intracranial extension. Conclusion: The COVID-19-related nationwide lockdown has deprived retinoblastoma patients of optimal and timely management, leading to prolonged treatment interruptions, delays, permanent default, and death. It is of paramount importance for all the stakeholders to increase awareness, make necessary travel and logistic arrangements, and ensure continuity of care for children with retinoblastoma.

Comparison of flow velocity in ophthalmic artery between glaucomatous and normal subjects.

Purpose: To study the hemodynamic parameters in ophthalmic artery (OA) using color Doppler imaging in subjects with primary open-angle glaucoma (POAG), normal-tension glaucoma (NTG) and age matched normals. Methods: Sixty-eight eyes of 68 subjects (41 males and 27 females) constituted material for this prospective observational study. They were divided into three groups; Group A had 24 patients with POAG, Group B had 18 patients with NTG and Group C had 26 normal subjects. They underwent CDI of OA. The outcome variables were peak systolic velocity (PSV), end diastolic velocity (EDV), resistivity index (RI) and pulsatility index (PI). Data were compiled and analyzed using one-way ANOVA analysis. Results: The mean ± SD age of POAG patients, NTG patient and normal subjects was 59.95 ± 7.35, 58.11 ± 9.97 and 57.73 ± 5.39 years, respectively. The mean intra ocular pressure (IOP) was 29.8 ± 5.0, 15.9 ± 2.4 and 16.6 ± 1.7mm Hg in Group A, B and C, respectively. In group A, the mean PSV, EDV, RI and PI were 18.2 ± 3.80, 3.71 ± 1.40, 0.93 ± 0.12 and 2.8 ± 0.42. In group B, 26.6 ± 1.72, 4.93 ± 1.32, 0.84 ± 0.02 and 1.32 ± 0.20 and in group C, 35.4 ± 3.04, 8.08 ± 0.69, 0.77 ± 0.03 and 1.80 ± 0.17, respectively. All the values were found to be statistically significant (p < 0.05). Lower PSV and EDV were found in POAG and NTG patients, while RI was higher than in normal subjects. Conclusion: The hemodynamic parameters are significantly affected in POAG and NTG patients. The PSV and EDV are decreased and RI is increased. EDV is more sensitive for the assessment of hemodynamic changes.

Angiostrongylus cantonensis in anterior chamber.

Live worm in anterior chamber is a rare finding. We hereby report a case of ocular Angiostrongylus cantonensis, which, to the best of our knowledge, is the third case report from India. A 70-year-old female presented with the complaints of watering and foreign body sensations in right eye since 2 months. On examination, a translucent worm of approximately 15 mm length was found freely moving in anterior chamber. Patient underwent surgical removal of live worm, which was identified as A. cantonensis. Educating people regarding importance of hygiene is important for prevention of worm infestation.

Bilateral combined anterior and posterior lenticonus in Alport's Syndrome.

Alport's syndrome is an inherited disease characterized by hearing loss, progressive renal failure and ocular abnormalities like anterior lenticonus, corneal opacities, cataract, fleck retinopathies, and temporal retinal thinning. To have anterior and posterior lenticonus in the same eye in this syndrome is a rare finding and only a few such reports are available. Hereby, we report a case of a 22-year-old male with bilateral combined anterior and posterior lenticonus with sensorineural deafness and nephritis leading to the diagnosis of Alport's syndrome.

Influence of learning effect on reliability parameters and global indices of standard automated perimetry in cases of primary open angle glaucoma.

Aim. To find out the influence of learning effect on various reliability parameters and global indices of standard automated perimetry in cases of primary open angle glaucoma. Method. Thirty eyes of 30 patients of Primary Open Angle Glaucoma constituted material for this prospective observational study. All the patients underwent standard automated perimetry three times on three different days within one week on G program of Octopus Visual Field Analyzer. The details of reliability indices, global indices, and test duration were compiled and analyzed. Result. A male preponderance was observed with a mean age of 53.43 years. The mean false positive was found to be 11.13, 6.07, and 2.40 on visit 1, visit 2, and visit 3, respectively. The mean false negative was found to be 13.73, 9.33, and 6.30 on visit 1, visit 2, and visit 3, respectively. The mean fixation loss was found to be 7.53, 3.83, and 1.60 on visit 1, visit 2, and visit 3, respectively. The mean deviation was found to be -10.14, -5.75, and -3.11 on visit 1, visit 2, and visit 3, respectively. The pattern standard deviation was found to be 5.58, 4.63, and 4.35 on visit 1, visit 2, and visit 3, respectively. The mean test duration was found to be 7.68, 6.21, & 5.51 minutes for visit 1, visit 2 and visit 3, respectively. All the values were statistically highly significant except for the pattern standard deviation. Conclusion. At least three standard automated perimetry tests should be performed for all glaucoma patients in order to obtain a base line perimetry chart.