Ocular manifestation of rickettsial disease in South Indian population.

Purpose: The aim of this work was to study the ocular manifestations and its management in spotted fever and typhus group of rickettsial disease. Methods: A retrospective analysis of 50 patients with serologically confirmed Rickettsial disease. In all patients, relevant history, investigations and treatment details were collected and they underwent complete ophthalmic evaluation including measurement of best-corrected visual acuity, anterior segment examination and dilated fundus examination. Results: Mean age was 12.5 ± 8.99 years. Of the 50 patients, 40 patients were ≤18 years of age and 27 (54%) had ocular involvement. Out of 27 patients, bilateral involvement was seen in 10 patients. Most of the patients had no ocular symptoms. Ocular findings included, Retinal vasculitis 6 (22.22%); macular edema 4 (14.81%); vasculitis with macular edema 1 (3.7%); Retinitis 7 (25.92%); Papilloedema 6 (22.22%); Papilloedema with 6th cranial nerve palsy 1 (3.7%); Isolated 6th cranial nerve palsy 1 (3.7%) and optic neuritis 1 (3.7%). Ocular involvement was more common in double antigen group (68%) than spotted fever group (50%) or Scrub typhus group (21%) (P = 0.01). Ocular involvement was seen in 94% of the patients with CNS involvement. Cases with bilateral involvement (P = 0.01), pediatric age group (P = 0.01) and CNS involvement (P = 0.02) had poor visual outcome. Conclusion: Rickettsioses patients can have ocular manifestations with predominant posterior segment involvement during acute phase of illness. Ocular involvement was more common in the double antigen group. For any patient who presents with fever and rash living in endemic area, ophthalmic evaluation should be part of routine checkup during the acute phase of illness associated with less frequent ocular symptoms.

Evaluating the Viability of a Smartphone-Based Annotation Tool for Faster and Accurate Image Labelling for Artificial Intelligence in Diabetic Retinopathy.

INTRODUCTION: Deep Learning (DL) and Artificial Intelligence (AI) have become widespread due to the advanced technologies and availability of digital data. Supervised learning algorithms have shown human-level performance or even better and are better feature extractor-quantifier than unsupervised learning algorithms. To get huge dataset with good quality control, there is a need of an annotation tool with a customizable feature set. This paper evaluates the viability of having an in house annotation tool which works on a smartphone and can be used in a healthcare setting. METHODS: We developed a smartphone-based grading system to help researchers in grading multiple retinal fundi. The process consisted of designing the flow of user interface (UI) keeping in view feedback from experts. Quantitative and qualitative analysis of change in speed of a grader over time and feature usage statistics was done. The dataset size was approximately 16,000 images with adjudicated labels by a minimum of 2 doctors. Results for an AI model trained on the images graded using this tool and its validation over some public datasets were prepared. RESULTS: We created a DL model and analysed its performance for a binary referrable DR Classification task, whether a retinal image has Referrable DR or not. A total of 32 doctors used the tool for minimum of 20 images each. Data analytics suggested significant portability and flexibility of the tool. Grader variability for images was in favour of agreement on images annotated. Number of images used to assess agreement is 550. Mean of 75.9% was seen in agreement. CONCLUSION: Our aim was to make Annotation of Medical imaging easier and to minimize time taken for annotations without quality degradation. The user feedback and feature usage statistics confirm our hypotheses of incorporation of brightness and contrast variations, green channels and zooming add-ons in correlation to certain disease types. Simulation of multiple review cycles and establishing quality control can boost the accuracy of AI models even further. Although our study aims at developing an annotation tool for diagnosing and classifying diabetic retinopathy fundus images but same concept can be used for fundus images of other ocular diseases as well as other streams of medical science such as radiology where image-based diagnostic applications are utilised.

Assessment of Circulating Biomarkers in Relation to Various Stages of Diabetic Retinopathy in Type 2 Diabetic Patients-A Cross Sectional Study.

AIM: The aim of this study is to examine the relationship between inflammatory markers, and diabetic retinopathy in type II diabetic patients. METHODS: The study was a cross-sectional study included 150 type 2 diabetic patients who were divided into 3 groups. 50 in each group are divided as Diabetic patients without retinopathy (DM, n=50), nonproliferative diabetic retinopathy patients (NPDR, n=50), proliferative diabetic retinopathy patients (PDR, n=50). All the patients were subjected to complete clinical examination and laboratory investigations, such as fasting and postprandial blood glucose, serum creatinine, lipid profile tests, glycosylated haemoglobin (HbA1c), fasting insulin, serum inflammatory markers (TNF-alpha, C-reactive protein) and serum VEGF. RESULTS: The study revealed from the multivariate analysis that age, duration and WHR (waist-hip ratio) are potent risk factors responsible for the risk of Diabetic retinopathy. Similarly, serum creatinine, CRP, TNF- alpha and VEGF are significantly higher in diabetic patients with retinopathy compared to diabetic patients without retinopathy. CONCLUSION: The study concluded that inflammation was associated with severe diabetic retinopathy in patients with well-controlled diabetes. A possible relationship was provided between the risk factors and biomarkers which are responsible for Diabetic retinopathy. Hence, modifying the risk factors risk and development of severe diabetic retinopathy can be reduced.

Can cryotherapy be used as an adjunct in select cases of recalcitrant endophthalmitis? - A case report.

We report two cases of recalcitrant endophthalmitis, a delayed postoperative fungal endophthalmitis following cataract surgery and an atypical mycobacterial endogenous endophthalmitis associated with infective scleritis. Due to recalcitrant nature of the endophthalmitis, one or more sittings of double freeze and thaw cryotherapy was applied over and adjacent to the infective foci in each case. This cryotherapy was used as an adjunct alongside conventional endophthalmitis management following which resolution of infection was observed in both cases.

Endophthalmitis caused by gram-positive bacteria resistant to vancomycin: Clinical settings, causative organisms, antimicrobial susceptibilities, and treatment outcomes.

PURPOSE: To report the clinical settings, causative organisms, antimicrobial susceptibilities, and treatment outcomes of patients with endophthalmitis caused by gram-positive bacteria resistant to vancomycin. METHODS: Retrospective case series of all patients with culture-proven endophthalmitis caused by gram-positive bacteria resistant to vancomycin between January 2010 and December 2016 in LV Prasad Eye Institute, Visakhapatnam, India. RESULTS: The current study included 14 patients. The clinical settings were post-cataract surgery in 8/14 (57.1%) and open globe injury in 6/14 (42.8%). Primary intervention for all patients included tap and intravitreal antibiotic injection. During subsequent follow-up, pars plana vitrectomy was performed in 6 patients and one patient underwent penetrating keratoplasty. Mean number of intravitreal antibiotic injections performed were 3.4 per patient. The most common organisms isolated were coagulase-negative Staphylococci in 6/14 (42.8%), Staphylococcus aureus in 5/14 (35.7%), Streptococcus sp in 2/14 (14.2%) and Bacillus sp in 1/14 (7.14%). In addition to vancomycin, resistance to multiple drugs (three or more groups of antibiotics) was found in all 14 cases. Antimicrobial susceptibility results showed susceptibility to amikacin in 7/14 (50.0%), gatifloxacin in 6/14 (42.8%), moxifloxacin in 3/13 (23.0%), cefazoline in 5/14 (35.7%), cefuroxime in 3/14 (21.4%), ciprofloxacin in 2/14 (14.2%) and linezolid in 5/5 (100%). The mean duration of follow-up was 30.7 weeks (6 weeks-90 weeks). At last follow-up, visual acuity (VA) of 20/200 or better was recorded in 7/14 (50%) and VA < 5/200 occurred in 7/14 (50%). CONCLUSION AND IMPORTANCE: Antimicrobial susceptibility testing may help in selection of suitable antimicrobial agents for repeat intravitreal injection. Inspite of retreatment with intravitreal antibiotics, these patients generally had poor VA outcomes.

Coexisting choroidal neovascularization and active retinochoroiditis-an uncommon presentation of ocular toxoplasmosis.

BACKGROUND: Choroidal neovascularization during the active stage of Toxoplasma retinochoroiditis is an uncommon clinical presentation. The authors retrospectively reviewed medical charts of patients with coexisting choroidal neovascular membrane and active Toxoplasma retinochoroiditis. FINDINGS: Three patients presented with coexisting choroidal neovascular membrane and active Toxoplasma retinochoroiditis. All lesions had adjacent subretinal hemorrhage. The diagnosis was confirmed based on clinical presentation, fundus fluorescein angiography (FFA), and optical coherence tomography (OCT) findings. The patients were managed with a combination of treatments including intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF), oral anti-Toxoplasma treatment, and oral corticosteroids. In all patients, the retinitis lesion resolved in 6 weeks and the coexisting choroidal neovascular membrane resolved over 6 to 12 weeks. CONCLUSIONS: Recurrences in Toxoplasma retinochoroiditis are common as satellite lesions adjacent to an old atrophic scar. Coexisting choroidal neovascularization with active Toxoplasma retinochoroiditis is an important presentation and should be suspected in the presence subretinal hemorrhage and managed with a combination of anti-Toxoplasma treatment and intravitreal anti-VEGF.

Conjunctival rhinosporidiosis.

A 12-year-old boy presenting with redness and foreign body sensation in his right eye was found to have a granular, pedunculated mass in the upper palpebral conjunctiva near the lid margin. After the mass was excised, the conjunctiva healed completely, with mild overlying scarring. At 6 weeks' follow-up, there was no evidence of recurrence. Histopathological examination of the mass revealed multiple sporangia characteristic of conjunctival rhinosporidiosis.