Optical coherence tomography angiography in preterm-born children with retinopathy of prematurity.

PURPOSE: To describe the foveal avascular zone (FAZ) and vessel density (VD) in the superficial and deep capillary plexus in children with a history of prematurity on optical coherence tomography angiography (OCTA) and their correlation with gestational age (GA) and birth weight (BW). METHODS: We enrolled 81 preterm- and eight term-born children in this prospective observational study. The Optovue RTVue AVANTI (Optovue Inc., Fremont, CA) was used to procure the OCTA images. The 3 × 3 mm scan protocol centered on the fovea and the central 1 mm of the grid along with the FAZ of the superficial capillary plexus (SCP) and deep capillary plexus (DCP) was acquired. RESULTS: The mean SCP-VD was comparable between the preterms and term controls (p = 0.315) in the central fovea (1-mm grid). However, the SCP-VD of the 3-mm grid was lower in the preterms born without ROP, with type 1 ROP, and with type 2 ROP (47.61, 47.90, and 48.82 respectively) compared to that in the term group (51.38; p = 0.031). The FAZ in the SCP (p = 0.003) and DCP (p = 0.003) was significantly smaller in the preterms compared to that in the controls. Based on the GA sub-analysis, the FAZ was significantly smaller in the SCP and DCP of preterms born < 31 weeks and > 31 weeks GA (p < 0.000, p < 0.035, respectively). Based on the BW, the difference between the FAZ in the SCP (p = 0.002) and DCP (p = 0.003) was significant. There was no association between the visual acuity and FAZ. CONCLUSION: Optical coherence tomography angiography findings in this study show an altered foveal morphology and vascularity in preterms with and without ROP.

Use of Wavefront Imaging Technology to Demonstrate Improvement in Corneal Aberrations Using Piggyback Contact Lens in a Keratoconus Eye With Intrastromal Corneal Ring Segment Implantation: A Case Report.

OBJECTIVE: To quantify short-term changes in corneal high-order aberrations (HOA) with piggyback contact lens use in an eye with keratoconus that had undergone intrastromal ring segment (Intacs) implantation. METHODS: A patient with keratoconus reporting of distorted images after Intacs surgery was found to have HOA (trefoil, point spread function [PSF], and modulation transfer function [MTF]) as measured using wavefront technology (Nidek OPD-Scan III) and evidenced by her cylindrical correction. She underwent piggyback contact lens (silicone hydrogel and fluoroperm rigid gas-permeable lenses) fitting in an attempt to improve the HOA. RESULTS: After piggyback contact lens fitting, her visual acuity improved and all her visual symptoms resolved. High-order aberrations reduced from 3.152 to 0.490 after the lens fitting and was noted to be 0.447 at 6 months; trefoil also significantly improved (0.360-0.096; it was 0.031 at 6 months). The cylinder decreased from -4.50 to -0.75 and was stable at 6 months (-1.00). There was also significant improvement in PSF and MTF. CONCLUSIONS: Visual acuity and symptoms along with HOA and cylinder improved after fitting of piggyback contact lens in our patient with keratoconus who had undergone Intacs.

COMPARING THE OUTCOME OF SINGLE VERSUS MULTIPLE SESSION LASER PHOTOABLATION OF FLAT NEOVASCULARIZATION IN ZONE 1 AGGRESSIVE POSTERIOR RETINOPATHY OF PREMATURITY: A Prospective Randomized Study.

PURPOSE: To compare single versus 2-session laser photoablation for flat neovascularization in cases with Zone 1 aggressive posterior retinopathy of prematurity. METHODS: Twenty-nine Asian Indian infants with aggressive posterior retinopathy of prematurity were randomized; each eye received 1 of 2 methods (29 each in Group A or B) proposed by the PHOTO-ROP group. Group A underwent single session laser to the avascular retina underlying the flat neovascularization by direct laser over the fronds. Group B underwent laser in 2 sessions; first, laser was delivered to the avascular periphery up to the flat neovascularization and 7 days later to the avascular bed exposed by the retraction of the fronds. Outcome and complications between the two groups were compared. RESULTS: Mean birthweight and gestational ages were 1,276 g and 30.1 weeks, respectively. All eyes showed favorable outcome at a minimum 12-month follow-up. Hemorrhages after laser (41.4% vs. 17.2%, P < 0.001) were more common in the single laser group. Large hemorrhages (>1 disk diameter) seen in Group A took longer than 8 weeks to resolve and developed focal fibrosis. CONCLUSION: This study demonstrates that the two-staged laser procedure produces fewer and smaller hemorrhages and no fibrosis compared with a single session. Both methods have comparable favorable outcomes in Asian Indian infants.

Comments on 'Presumed Post-COVID Infection Retinitis - Clinical and Tomographic Features of Retinitis as a Post-COVID Syndrome'.

Characteristics and course of known seasonal diseases of pre-coronavirus disease (COVID-19) pandemic era may or may not change during the pandemic. Labelling COVID-19 as a novel etiology for those seasonal diseases or considering it as coinfection is debatable. Appropriate investigations are required to rule out previously known etiologies before correlating it with COVID-19. Epidemic retinitis (ER) or post fever retinitis is one such entity with seasonal variation. Multiple seropositivity for various organisms has been reported for ER during pre-pandemic era. This may significantly increase during the pandemic as the possibility of coinfection with COVID-19 is high. In the absence of gold-standard tests to exclude previously reported causes of ER, one should not undermine the possible coinfection before considering ER as post-COVID-19 syndrome. A study of incidence and pattern of seasonal variation of ER before and during the pandemic is needed before presumptively associating it with COVID-19.

Monitoring Weil-Felix test in epidemic retinitis.

Purpose: The objective was to study the positivity of the Weil-Felix test (WFT) in epidemic retinitis (ER) during the course of the disease. Methods: This is a retrospective, observational case series of patients diagnosed with ER and presented to a tertiary eye care hospital in south India. Patients with positive WFT at the presentation, and who underwent a follow-up WFT during or after the resolution of ER were studied from September 2019 to March 2022. Patient's demographics, timings of clinical presentation and resolution, and investigation details with a special focus on WFT positivity and its duration were noted. Results: Sixteen patients were studied. Patients presented after 5 weeks of the fever (range: 2-12 weeks, median: 4). After 1-2 months, WFT was still positive in eight patients (50%). Only in one patient titers increased after 1 month, while in others, the titers decreased (n = 11) or remained the same (n = 4). Repeated tests in those patients (n = 6) after 3-4 months turned negative. Resolution of ER was seen at 1.35 months (range: 1-3 months) after the presentation. The mean duration for WFT to turn negative was 2 months from the presentation (range: 1-4 months) or 3.2 months of the fever (range: 1.5-6 months). Conclusion: In contrast to the reported physician's observation of increasing titers of WFT after rickettsial fever, ophthalmologists may observe decreasing WFT titers in ER. The clinical resolution of ER may precede the normalization of WFT. Follow-up WFT titers should be studied in larger series in confirmed cases of rickettsial-ER to validate the affordable and readily available WFT in India.

Epidemic retinitis during the COVID-19 pandemic.

Purpose: To study the impact of the novel coronavirus disease-2019 (COVID-19) pandemic on incidence, seasonal variation, clinical presentation, and disease outcome of epidemic retinitis (ER) and to compare clinical outcomes with positive and negative COVID-19 serology. Methods: This is a retrospective, observational study conducted at a tertiary eye care hospital from August 2020 to June 2022. A graph of ER cases against the month of presentation was compared with the graph of the COVID-19 pandemic in the same region. Cases presented before COVID-19 vaccination, with positive COVID-19 serology (Group 1) were compared with cases with negative serology (Group 2). Results: One hundred and thirty-two cases of ER were seen. The least number of cases were seen during and immediately after the peak of the pandemic (May 2021-August 2021). COVID-19 serology was positive in 13 (22 eyes)/60 (21.6%) unvaccinated cases. Along with COVID-19, positive serology for other ER etiologies was seen in 5/13 cases (38.4%). All patients received oral doxycycline with/without steroids. Groups 1 and 2 included 22 and 21 eyes of 13 cases each. Macular edema resolved in 43.6 and 32 days in groups 1 and 2, respectively. Retinitis resolved at 1 month in both groups. Corrected distant visual acuity was 20/50 and 20/70 at the presentation, which improved to 20/20 and 20/25 in groups 1 and 2, respectively. Mean and median follow-up was 6 months and 4.5 months, respectively, in both groups. No complications or recurrences were seen. Conclusion: No significant impact of the COVID-19 pandemic on ER was observed.

Epidemic retinitis during pregnancy.

Purpose: To study the clinical presentation and treatment outcome of epidemic retinitis (ER) during pregnancy. Methods: This is a retrospective, observational chart review of pregnant patients diagnosed with ER from January 2014 to February 2023. Demographic details, month of pregnancy at the onset of ocular symptoms, history of present illness, clinical manifestations, and treatment outcomes were studied. Results: In 9 years, ER was seen in 86 females, of whom 12 (13.9%) were pregnant. Twenty-one eyes of those 12 patients were studied. Most of the patients presented in the sixth month of pregnancy (range: 5-9 months, mean: 6.3 months). Physicians diagnosed viral exanthematous fever in six, typhoid in three, and suspected rickettsia in one patient. Medical termination of pregnancy (MTP) was performed in two patients before presentation. Weil-Felix test was positive in five, Brucella in one, WIDAL in three, and coronavirus disease 2019 (COVID-19) IgG and dengue IgG in one patient each. Oral antibiotics were given in five patients (two post-medical termination of pregnancy [MTP]) for the retinitis. All except four received oral steroids. Mean presenting corrected distant visual acuity (n = 21) was 20/125 (range: 20/20-20/20,000), which improved to (n = 18) 20/30 (range: 20/20-20/240). Macular edema (n = 11) resolved in 33.18 days (range: 20-50 days), and retinitis (n = 13) resolved in 58 days (range: 30-110 days). Ocular and systemic examination of newborn was possible in two and the babies were normal. Conclusion: ER is seen commonly at the beginning of the third trimester. Lack of antibiotics may delay the resolution of retinitis. Ocular health needs to be assessed in larger series to conclude absence of retinal involvement in newborns.

Socioeconomic factors in childhood cataracts - A descriptive study from a tertiary eye care center in India.

Purpose: While there are a few studies that show the prevalence of blindness and ocular morbidity in children, studies on socioeconomic factors in childhood cataracts are scarce. We aimed to study the socioeconomic status, education and occupation of the parents, consanguinity, and gender inequality among children presenting with cataracts. Methods: This was a hospital-based, prospective, descriptive study of 68 children with cataracts (aged 0-18 years). In addition to the data on clinical parameters and surgical management, we also collected data on age, gender, age at which the chief complaint was noticed, consanguinity of parents, socioeconomic class, and occupation and education of parents. All statistical analyses were performed using MedCalc statistical software (MedCalc Software 2019, Ostend, Belgium). Results: Sixty-eight children with pediatric cataract, out of which 36 were bilateral, were studied. Thirty children (44%) were in the age group of 1-5 years. Out of the 36 bilateral cataracts, 25 (69.44%) were males and 11 (30.56%) were females. Thirty (44.1%) had a delayed presentation. Also, 31% belonged to middle class and 28% belonged to lower middle class. Moreover, 65% of the mothers had an undergraduate education. Conclusion: There is a gender-based inequality and late presentation of childhood cataracts. To improve early detection, red reflex screening should be mandatorily done. Further studies are required to identify barriers to access of eye care specific to girls, in order to plan interventions to improve uptake of treatment. The lower socioeconomic status of the patients should be taken into account in the management of this disease.

Pole-to-pole involvement of varicella zoster virus reactivation following COVID-19 vaccination.

The aim of this study is to report the clinical features, imaging findings including confocal imaging, corneal nerve fiber analysis, and management outcomes in a series of three cases of varicella zoster virus (VZV) reactivation following one dose of coronavirus disease 2019 (COVID-19) vaccination. This was a retrospective and observational study. All the patients who developed uveitis post-vaccination were pooled together. Patients who had VZV reactivation were included. Two cases had polymerase chain reaction positive for VZV from aqueous humor. At the time of presentation, IgG and IgM spike protein antibodies for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) were tested. Out of this pool, three patients with classical features to describe pole-to-pole manifestations were chosen. A 36-year-old lady with post-vaccination sclerokeratouveitis associated with reactivation of herpes zoster ophthalmicus, a 56-year-old lady with post-vaccination acute anterior uveitis associated with herpes zoster ophthalmicus, and a 43-year-old gentleman with post-vaccination acute retinal necrosis were included. We present a possible link between anti-SARS-CoV-2 virus vaccination and varicella zoster reactivation in these patients and also describe the clinical features, imaging findings including confocal imaging, corneal nerve fiber analysis, and management with detailed discussion.

Epidemic retinitis - Factors associated with poor visual outcomes.

PURPOSE: To identify factors other than macular edema and retinitis location responsible for poor visual outcomes in epidemic retinitis (ER). METHODS: A.retrospective, observational, comparative study. Eyes with corrected distant visual acuity (CDVA) 20/200 or worse at resolution formed Group A. Eyes with central macular thickness (CMT) 600 µm or worse and retinitis within 1500 µm to foveal center at the presentation, but improved to CDVA 20/200 or better at the resolution formed Group B. The patient's history, clinical presentation, imaging, and treatment outcomes were studied and the factors responsible for the final visual outcomes were compared in both groups. RESULTS: Groups A and B included 25 eyes each. The mean CDVA at the presentation was 20/400 (range: 20/125-20000) and 20/320 (range: 20/80-20000), and mean CMT at the presentation was 948.5 µm (range: 520-1553) and 912.2 µm (range: 615-1250) in Groups A and B, respectively. All eyes except 1 (Group A) had retinitis lesions within 1500 µm of foveal center. The mean CDVA at the resolution was 20/400 (range: 20/200-20/20000) and 20/40 (range: 20/20-20/80) in Groups A and B, respectively. Older age, male gender, diabetic status, delayed presentation, poor presenting CDVA, bilaterality, presence of keratic precipitates, disk pallor, retinal thinning, and subfoveal deposits had a statistically significant association, whereas the absence of skin rash, ellipsoid zone loss, negative WIDAL, Weil-Felix test, and delayed doxycycline therapy or use of steroids without doxycycline had a statistically insignificant association with poor visual outcomes. CONCLUSION: Apart from presenting CMT and location of retinitis, multiple demographic, clinical, and imaging factors can be implicated for poor visual outcomes.

Epidemic Retinitis with Positive or Negative Weil Felix Test - a Comparative Study and Outcome with Doxycycline.

PURPOSE: To compare clinical manifestations and disease outcomes in Epidemic Retinitis (ER) with positive or negative Weil Felix Test (WFT). METHODS: Retrospective, observational, comparative study. WFT positive or negative patients formed Group 1 and 2, respectively. Patients receiving oral doxycycline monotherapy formed subgroup A and B. Duration of resolution of macular edema and retinitis was compared. RESULTS: Novel finding of "ring retinitis" was observed equally in group 1 and 2. Complete resolution of macular edema took 41.3 days (range: 30-60 days) and 43.68 days (range: 20-105 days) (p = .668) and retinitis lesions resolved in 34.3 days (range: 14-65 days) and 34 days (range: 12-60 days) (p = .875) in group A and B, respectively. All (n = 14) eyes with retinitis within 1 disc diameter of fovea improved better than 20/80 except 1. CONCLUSION: No significant difference with respect to clinical, imaging findings and the treatment outcome was observed in WFT positive or negative cases.

Trends in teleconsultations for uveitis during the COVID-19 lockdown.

Purpose: To study the use of teleophthalmology as a tool to manage patients with uveitis and to describe the experience of teleconsultation for uveitis at a tertiary eye care hospital in India during the two waves of the COVID-19 pandemic. Methods: A prospective observational case series of uveitis patients seeking teleconsultations during the first (March 25-May 2020) and second lockdown (April 27 to June 21, 2021) in a tertiary eye care center were analyzed. Results: There were 79 teleconsultations in the first and 89 teleconsultations in the second lockdown. A majority of the patients presented in the age group of 41-60 years in both the lockdowns. There were both new or primary consultations and follow-up patients (6% vs. 94%) in the first lockdown, and similarly in the second lockdown (8% new vs. 92% follow-up). The majority of patients resided in Bengaluru city (78% in the first and 76% in the second lockdown). After evaluation through video consultation, only 15% required a hospital referral in the first lockdown, whereas in the second lockdown, 21.3% were referred to the hospital. During the second lockdown, 20% presented with COVID-19 infection-related ailments. Conclusion: Based on our preliminary experience using a customized smartphone-based application for teleconsultation, we found it to be an alternative option to provide continuation of ophthalmic care to uveitis patients. Given the current COVID-19 situation, it can help avoid physical visits of uveitis patients to the hospital.

Epidemic Retinitis with Macular Edema -Treatment Outcome with and without Steroids.

Purpose: To study treatment outcomes with and without oral corticosteroids in epidemic retinitis (ER).Method: A retrospective, observational study of 35 eyes of 29 patients diagnosed as ER. Days taken for resolution of macular edema and retinitis lesions were compared in patients treated with oral antibiotics (Group 1) and with corticosteroids-antibiotics combination (Group 2).Result: Eighteen eyes of 14 patients and 17 eyes of 15 patients formed Groups 1 and 2, respectively. At the presentation, mean best-corrected visual acuity (BCVA) was 40 and 44 letters and mean central macular thickness was 648 (±243) and 626 (±256) microns in Groups 1 and 2, respectively. Macular edema resolved in 30.83 and 31.94 days; retinitis lesions resolved in 36.71 and 41.41 days in Groups 1 and 2, respectively. BCVA improved to 74 and 77 letters in Groups 1 and 2, respectively.Conclusion: ER with macular edema can be well managed without corticosteroids.

Evaluating Contrast Sensitivity in Asian Indian Pre-Term Infants With and Without Retinopathy of Prematurity.

Purpose: The purpose of this study was to evaluate the contrast threshold in Asian Indian preterm infants with and without retinopathy of prematurity (ROP) using Newborn Contrast Cards measured during the first ROP screening and to correlate with final outcome and visual acuity at 3 months of corrected age. Methods: Preterm infants born ≤ 2000 grams birth weight (BW) and/or ≤ 34 weeks gestational age (GA) undergoing ROP screening were enrolled prospectively. Visual acuity was recorded using Teller Acuity Cards. Contrast threshold was measured with Newborn Contrast Cards at first screening visit and at the end of ROP screening at 40 weeks of postmenstrual age or older. Results: Of the 173 study infants, 134 (77.5%) did not have any stage of ROP. Of the remaining 39 (22.5%), 34 (87%) had type 2 ROP and 5 (13%) had type 1 ROP requiring treatment. The mean contrast threshold at the first visit of the no ROP type 1 and type 2 groups was 0.36 ± 0.07, 0.65 ± 0.19, and 0.46 ± 0.09, respectively (P < 0.001). Contrast threshold had a significant correlation with BW (R = -0.291, P = < 0.001) and gestational age (R = -0.47, P = < 0.001). The contrast threshold at the first visit correlated with visual acuity measured at 3 months of corrected age in logMAR (R = 0.36, P = 0.01). Other than BW and GA, no other systemic risk factors correlated with contrast threshold measured at the first screening visit. Conclusions: Newborn Contrast Cards are a viable tool to test contrast threshold in preterm infants. The association between contrast threshold and ROP, and its correlation with visual acuity, suggest that contrast threshold measurement may help predict the clinical vision outcome among prematurely born infants. Translational Relevance: Contrast threshold measurement may prove to be a useful tool in the estimation of visual potential in preterm infants.

Propensity of aerosol and droplet creation during oculoplastic procedures: A risk assessment with high-speed imaging amidst COVID-19 pandemic.

PURPOSE: The study uses principles of liquid and gas mechanics to verify and quantify the generation of aerosols in oculoplastic procedures, namely surgery using a scalpel, electrosurgical device, and a mechanized drill. METHODS: Surgical techniques were performed ex vivo using the electrosurgical device, scalpel, and mechanized drill on the muscle and bone of commercially available chicken. The liquid and gas dynamics were observed using a high-speed high-resolution Photron SA5 camera (0.125 to 8 ms temporal resolution, 0.016 to 0.054 mm/pixel spatial resolution) and stroboscopic lighting (Veritas 120 E LED Constellation). The analysis was performed using in-house algorithms and ImageJ software. RESULTS: The use of a mechanized drill at 35000 rpm and a 3 mm fluted burr generated aerosol with particle size 50 to 550 microns with a spread of 1.8 m radius. Surgical smoke was generated by an electrosurgical device in both cutting and coagulation modes. Dispersion of the smoke could be controlled significantly by the use of suction, mean smoke spread ratio being 0.065 without suction and 0.002 with use of suction within 2 cm. CONCLUSION: The quantification of the aerosol generation will help surgeons take practical decisions in their surgical techniques in the pandemic era.

In vivo confocal microscopy of keratic precipitates in infectious versus noninfectious uveitis.

PURPOSE: To test the hypothesis that morphologic patterns of keratic precipitates (KPs) evaluated by in vivo confocal microscopy (IVCM) can differentiate infectious from noninfectious uveitis. DESIGN: Cross-sectional, observational case series. PARTICIPANTS: Sixty-eight eyes of 53 subjects with uveitis. METHODS: A cross-sectional study was performed in patients with infectious and noninfectious uveitis presenting to a tertiary care eye hospital. Detailed ophthalmologic evaluation was performed in all the subjects. Keratic precipitates were studied by IVCM using the HRT II Rostock corneal module (Heidelberg Engineering GmbH, Heidelberg, Germany) and categorized on the basis of morphologic patterns. MAIN OUTCOME MEASURES: Morphology of KPs by slit-lamp biomicroscopy and confocal microscopy. RESULTS: The age of patients ranged from 15 to 87 years (median 40 years). Thirty-two patients were male (60.37%). Thirty-eight subjects had a unilateral presentation (71.69%) of uveitis. Infectious uveitis was seen in 38 cases (71.69%). The characteristics in KPs as seen in infectious uveitis were dendritic, central globular with dendritic, and infiltrative. In noninfectious uveitis (28.3%), stippled, globular, and multiple globular types of KPs were found. The sensitivity, specificity, and positive predictive value for specific combinations of KPs with an infectious cause were 84.21%, 93.33%, and 96.96%, respectively. CONCLUSIONS: In vivo confocal microscopy can act as an adjunct tool for differentiating infectious from noninfectious uveitis. A central globular with dendritic form of KPs is strongly suggestive of infectious uveitis.

Functional involvement of cone photoreceptors in advanced glaucoma: a multifocal electroretinogram study.

The purpose of the study is (1) to demonstrate the anatomical variation of cone photoreceptor density across normal retina as a sectoral amplitude asymmetry of photopic multifocal electroretinogram (mfERG) and (2) to study the potential presence of sequential or differential, functional cone photoreceptor damage in glaucoma using this amplitude asymmetry. A 37-Block scaled mfERG was recorded from 22 controls and 27 glaucoma subjects. The N1 and P1 amplitudes of averaged responses from corresponding zones nasal and temporal to fovea were analyzed for asymmetry in controls and glaucoma subjects. Amplitude asymmetry was demonstrable for both N1 (p < 0.001) and P1 (p < 0.001) parameters in control subjects. Although this amplitude asymmetry was preserved in glaucoma subjects with moderate field defects, it was not demonstrable in patients with advanced field defects. The anatomical variation in cone photoreceptor distribution across normal retina is demonstrated as an amplitude asymmetry in first order kernel responses of mfERG. The cone photoreceptors in the region nasal to fovea appear to be affected only in advanced glaucoma possibly suggesting that photoreceptors could follow a sequential damage like the overlying neuroretinal rim in glaucoma.

Epidemic retinitis and community outbreaks.

PURPOSE: The objective of this study was to correlate seasonal variation of epidemic retinitis (ER) with concurrent community outbreaks. METHODS: This is a retrospective, observational, comparative study conducted in a tertiary care eye hospital in south India. Monthly variation in number of ER cases in comparison with reported community outbreaks by Integrated Disease Surveillance Program (IDSP) from 2009 to 2020 in the same region were studied. Month-wise graphs against number of patients were plotted for ER and for each community outbreak. RESULTS: ER was diagnosed in 163 patients. Diagnosis of presumed rickettsial ER was made in 48 cases (29.44%), chikungunya in 5, dengue in 3 and typhoid in 6 cases, while in other cases the etiological diagnosis remained uncertain (n = 101). Multiple positive serological tests were seen in 6 patients (Weil Felix Test (WFT) with WIDAL in 4 and chikungunya IgM with WFT in 2 patients). Relevant reported outbreaks by IDSP were: Pyrexia of unknown origin (PUO) (n = 5148), Chikungunya (n = 6577), Dengue (n = 7350), Measles (n = 1422), Mumps (n = 881), Rubella (n = 288), Malaria (n = 2262), Chicken Pox (n = 2385), Typhoid (n = 597), Kyasanur Forest Disease (n = 381), Scrub Typhus (n = 13), Typhus fever (n = 4), Japanese Encephalitis (n = 15). None of the outbreak graphs pattern was identical or similar to the graph of ER. Inverse relation of the graph of dengue outbreak with ER was observed. CONCLUSION: Inverse correlation between dengue and ER should be further studied for causation, which we believe may prove dengue as least common cause. Reporting of rickettsial outbreaks should be enhanced by undertaking statewide awareness and procurement of gold standard tests.