Central Retinal Artery Occlusion in COVID-Associated Mucormycosis.

Introduction: Significant surge of mucormycosis was reported in the Indian Subcontinent during the second wave of the COVID-19 pandemic. COVID-associated mucormycosis (CAM) was defined as the development of features of mucormycosis with prior or current history of COVID-19 infection. Rapid angioinvasion is an important characteristic of mucormycosis. Authors intended to find out the prevalence of retinal arterial occlusion and its association with vascular embolic occlusion elsewhere in the body among CAM patients in this study. Methods: This was an observational study. All consecutive-confirmed cases of mucormycosis (n = 89) and age-/gender-/risk factor-matched controls (n = 324) admitted in the designated COVID center were included in the study. All cases and controls underwent comprehensive ophthalmological, otorhinological, and neurological examinations. All necessary investigations to support the clinical diagnosis were done. Qualitative data were analyzed using the Chi-square test. Quantitative data for comparison of means between the cases and controls were done using unpaired t-test. Results: Twenty-one (23.59%) patients manifested the defined outcome of central retinal artery occlusion (CRAO). Among age-matched control, with similar diabetic status, none had developed the final outcome as defined (P < 0.05). About 90.47% of subjects with CRAO presented with no perception of light vision. Thirteen subjects (61.9%) with the final outcome developed clinical manifestations of stroke during the course of their illness with radiological evidence of watershed infarction (P = 0.001). Orbital debridement was performed in 9 (42.85%) subjects while orbital exenteration was done in 8 (38.09%) subjects. Conclusions: CRAO in CAM patients was found to have aggressive nature turning the eye blind in a very short period of time. CRAO can serve as a harbinger for subsequent development of more debilitating and life-threatening conditions such as stroke among CAM patients.

Evaluation of post-operative dry eye in upper and lower eyelid reconstruction: A cross-sectional study.

Purpose: In cases of eyelid malignancies requiring full thickness excisional biopsy followed by reconstruction of the created defect, the Meibomian glands are lost. Post-operative varying degrees of dry eye disease (DED) are expected in such patients. The aim was to evaluate the objective and subjective statuses of DED in cases of full thickness eyelid reconstruction following excisional biopsy because of malignancies. Methods: This was a cross-sectional pilot study. Objective and subjective dry eye parameters are assessed in cases of full thickness eyelid reconstruction following excisional biopsy because of malignancies in 37 eyes at 6 months post-operative follow-up. Analysis of variance and Chi square test were used for statistical analysis. Results: When compared with fellow eye, all the parameters were found to be statistically significant (P < 0.0). Subjective assessment of dry eye by ocular surface disease index (OSDI) scoring did not corroborate with the objective data (p 0.00). Lower eyelid reconstruction showed a minimum number of dry eye cases (P > 0.05). Conclusion: Prevalence of post-operative dry eye is more with increasing percentage of full thickness upper eyelid reconstruction. Disparity was found between objective and subjective parameters of dry eye in patients requiring varying percentages of upper eyelid reconstruction because of malignancies.

Clinical outcome of orbital apex syndrome in COVID associated mucormycosis patients in a tertiary care hospital.

AIM: To share clinical pattern of presentation, the modalities of surgical intervention and the one month post-surgical outcome of rhino-orbito-mucormycosis (ROCM) cases. METHODS: All COVID associated mucormycosis (CAM) patients underwent comprehensive multidisciplinary examination by ophthalmologist, otorhinolaryngologist and physician. Patients with clinical and radiological evidence of orbital apex involvement were included in the study. Appropriate medical and surgical intervention were done to each patient. Patients were followed up one-month post intervention. RESULTS: Out of 89 CAM patients, 31 (34.8%) had orbital apex syndrome. Sixty-six (74.2%) of such patients had pre-existing diabetes mellitus, 18 (58%) patients had prior documented use of steroid use, and 55 (61.8%) had no light perception (LP) presenting vision. Blepharoptosis, proptosis, complete ophthalmoplegia were common clinical findings. Seventeen (19.1%) of such patients had variable amount of cavernous sinus involvement. Endoscopic debridement of paranasal sinuses and orbit with or without eyelid sparing limited orbital exenteration was done in most cases, 34 (38.2%) patients could retain vision in the affected eye. CONCLUSION: Orbital apex involvement in CAM patients occur very fast. It not only leads to loss of vision but also sacrifice of the eyeball, orbital contents and eyelids. Early diagnosis and prompt intervention can preserve life, vision and spare mutilating surgeries.

Total or subtotal replacement of tarsal plate by novel silicone plate for upper eyelid reconstruction in malignant tumors.

PURPOSE: : To evaluate the cost, safety, surgical outcome, and efficacy of modified Cutler-Beard eyelid reconstruction utilizing a novel silicone plate as a tarsal plate replacement in the repair of 60% to 100% eyelid defects following the excision of large malignant tumors. METHODS: : A prospective, noncomparative, interventional study of 30 eyes was done over 3 years. Fourteen patients were female, and 16 patients were male. In all the cases, a silicone plate, the synthetic, artificial tarsal plate, was utilized for a total or subtotal replacement of the tarsal plate. The created defect was measured in mm (length and width) and later expressed in percentage. Pre- and postoperative action of levator palpebrae superioris (LPS) was measured. Pre- and postoperative measurements of the margin-to-margin reflex distance (MRD1) were noted. RESULTS: : Preoperative LPS action was 1.23 ± 1.35 mm, whereas postoperative LPS actions at the end of 1 week and 18 months were 11. 8 ± 0.88 mm and 13.53 ± 0. 73 mm, respectively. Preoperative MRD1 was - 3.0 ± 1.144 mm, whereas postoperative MRD1 values at the end of 1 week and 18 months were 2.18 ± 0.27 mm and 4.16 mm ± 0.35, respectively. The mean created defect after the removal of the tumor was 87.3% ±11.10. The mean length of the silicone plate implanted in this study was 27.53 ± 2.48 mm. The follow-up period for the study participants was 18 months. CONCLUSION: : The synthetic novel silicone plate was successful as a tarsal plate replacement. A second surgical site for ear cartilage harvesting is avoided. Cadaver transfer of Achilles tendon carries the risk of transmission of communicable diseases, for example, hepatitis B and HIV. Silicone is an inert, nonreacting, and tissue-tested material, thus eliminating the possibility of graft rejection. This material is readily available and cost-effective. The novel silicone plate is considered to be the most promising alternative material as a tarsal replacement in the future generation.

Surgical outcomes of Tenzel rotational flap in upper and lower lid reconstruction without repair of posterior lamella: A modified approach.

Aim: To evaluate the efficacy and usefulness of Tenzel rotational flap in upper and lower lid reconstruction in malignant tumors, to determine the anatomical alignment, functional, and cosmetic outcome after lid reconstruction and recurrence of the tumor and to observe the canthal and fornix status. Methods: Prospective, non-comparative,interventional clinical study of 30 patients over a period of 18 months. The study was conducted with strict inclusion and exclusion criteria. Evaluation parameters were LPS (Levator palpebrae superioris) action Pre and post operative, MRD-1 (Margin Reflex Distance-1) values pre and post operative, central vertical palpebral fissure height (PFH) pre and post operative,and the calculation of the created defect express in percentage preoperatively. None of the case posterior lamina was repaired. It formed or strengthened automatically. Results: The diagnosis of Sebaceous cell carcinoma was 14/30 by FNAC and 17/30 by histopathology. The mean MRD-1 pre-operatively was -1.09 ± 1.54 mm to 4.02 ± 0.36 mm postoperatively in the upper lid. The mean LPS action pre-operatively was 4.35 ± 0.96 mm to 12.42 ± 1.24 mm postoperatively in the upper lid tumor. The mean pre-operative central palpebral aperture was 4.76 ± 0.88 mm and post-operative central palpebral aperture was 10.47 ± 0.88 mm in the upper lid tumor. The mean incision length was 8.16 ± 0.61 mm in upper lid and 9.27 ± 0.87 mm in lower lid Tenzel reconstruction respectively. In all the cases, posterior lamella grew normally. In addition, no strengthening procedure was required. Conclusion: This reconstructive procedure was useful to repair 40%-60% of the upper lid and 40%-70% created a defect in the lower eyelid after the removal of the malignant tumor. Histopathological diagnosis of the specimen was more accurate than FNAC. No repair of posterior lamella was made. No extra surgical procedure was needed. Thus, the surgical procedure time was markedly reduced. After the surgery, all the patients presented a good uplift of the upper lid, good closure of the eyelids, and were visually and functionally well rehabilitated. The aesthetic appearance was excellent.

Surgical Outcomes of Unilateral Marcus Gunn Jaw Winking Ptosis Correction: A Novel Whitnall's Ligament Approach.

PURPOSE: To evaluate the surgical, functional, and cosmetic outcome in moderate to severe ptosis with Marcus Gunn jaw winking phenomenon and recurrence of disease after ptosis correction. This procedure has been emphasized on a child. METHODS: This was a prospective, non-comparative, interventional study conducted over 4 years on 30 people. The ages range from 7 to 40 years. The eyelid was approached from behind to identify the Whitnall's ligament. Levator palpebrae superioris was first disinserted then dissected up to the superior border of the tarsal plate followed by 20 to 25 mm by resection which causes disabling of the levator palpebrae superioris action. Subsequently, "tarso frontalis sling with silicon rod" for ptosis correction. Compared with the preoperative and postoperative photograph. RESULTS: Margin reflex distance 1 values are in the affected eye preoperative 1.8 ± 0.87 mm to postoperative 3.96 ± 0.41 mm. Preoperative palpebral fissure height are means 5.05 ± 0.62 mm to postoperative palpebral fissure height means 9.3 ± 0.71 mm. Ptosis significantly improved which is statistically significant (p < 0.05). Lid excursion or Flickering's in affected eyes preoperative means 6.1 ± 3.47 mm to postoperative after 1 year means are 0.43 ± 0.81 mm. Follow-up period is 1 year. CONCLUSIONS: Unilateral posterior approach (Whitnall's ligament approach) is found better in surgical, functional, and cosmetic outcomes in the correction of Marcus Gunn jaw winking syndrome, especially in children. The risk of bilateral extensive surgery is avoided. After the surgery, the primary gaze face photo identity was well-accepted in official government documents. This study is stressed on bilateral lid height similarity in primary gaze unlike the traditional method of downgaze similarities. The patients were highly satisfied both physically and mentally.