Post-Coronavirus Disease-2019 Rhino-orbital Mucormycosis: A Case Report.

BACKGROUND: Rhino-orbital-cerebral mucormycosis (ROCM) is a rare, opportunistic, angio-invasive, and fatal infection caused by mold fungi of the genera Rhizopus, Mucor, and Rhizomucor. The global incidence of ROCM is 0.005-1.7 per million, with a fatality rate of 46%. Early diagnosis and treatment are crucial for this disease, as a delay of one week can increase the mortality rate to 66%. CASE: A 32-year-old male, a known case of coronavirus disease 2019 (COVID-19) for the past 15 days from Janakpur, Dhanusha, Nepal presented to the emergency department of Dhulikhel Hospital with a sudden onset of blurred vision in the left eye, left-sided ocular pain, and nasal bleeding for the last three days. OBSERVATIONS: The patient was suspected of post-COVID-19 mucormycosis, and a nasal swab for potassium hydroxide (KOH) mount showed hyphae in microscopy. Intravenous and retrobulbar liposomal amphotericin B were administered as medical therapy, along with surgical debridement. A multidisciplinary approach was necessary for the treatment. CONCLUSION: A long-term, multimodal treatment approach involving combined antifungal drug therapy (intravenous liposomal amphotericin B and retrobulbar amphotericin B), and timely surgical debridement leads to an improvement in both short-term and long-term outcomes.

Severity of primary open-angle glaucoma in patients with hypertension and diabetes.

BACKGROUND: Primary open-angle glaucoma (POAG) is a progressive optic neuropathy with numerous risk factors. Its severity with associated risk factors remains a widely debated topic. AIM: To evaluate the severity of POAG in patients with hypertension (HTN) and diabetes or both. PATIENTS AND METHODS: This hospital-based, cross-sectional descriptive study was conducted for a period of 18 months from January 2016 to June 2017. Diagnosed cases of POAG were evaluated for severity with associated risk factors. RESULTS: A total of 221 patients were enrolled in the study. The mean age of the patients was 54.4 (SD ± 15.9) years with a male to female ratio of 0.93:1. Of the 221 patients, 68 (31%) had a family history of POAG. Mean intraocular pressure was 15.8±4.87 mmHg, and mean central corneal thickness was 535.4±34.9 µm. A total of 81 (36%) patients had HTN, 21 (9.50%) had diabetes mellitus (DM), and 15 (6.80%) had both HTN and DM. Analysis using SPSS version 20 was done. The severity of POAG was found to be significantly higher in patients with HTN, DM, or both when evaluated on the basis of anatomical and functional loss. CONCLUSION: POAG patients with HTN, DM, or both were found to have more severe POAG. Patients with these risk factors could represent "high-risk patients" with POAG. Patients with HTN and DM, or both may require evaluations on a more frequent basis to access the progression/severity of POAG.

Diabetic retinopathy with or without clinically significant macular edema: The influencing factors.

INTRODUCTION: Diabetic retinopathy is the commonest micro vascular complication in patients with diabetes and remains a leading cause of blindness in people of working age group. OBJECTIVE: to determine the prevalence of clinically significant macular edema (CSME) and the influence of systemic risk factors Materials and methods: It is a hospital based comparative study conducted in 220 eyes of 110 diabetic patients. DR was graded according to International Clinical Diabetic Retinopathy Severity Scale and CSME was defined according to Early Treatment Diabetic Retinopathy Study (ETDRS) system. The patients were grouped as 1) CSME group (DR and CSME in one or both eyes) and 2) Non- CSME group(CSME in none of the eyes but with any grade of DR).Level of glycosylated hemoglobin (HbA1C), serum total cholesterol, triglyceride (TG), low density lipoprotein (LDL), high density lipoprotein (HDL) and urine for albumin were studied in both groups. RESULTS: CSME was present in 36% of 110 patients. Poor glycemic control and high total cholesterol level showed positive association with CSME (p LESS THAN 0.05). LDL and TG levels were higher and HDL lower in CSME group. However, no statistical significance was found. CONCLUSION: The CSME is significantly associated with poorer glycemic control and elevated total cholesterol level.

Multifocal electroretinogram responses in Nepalese diabetic patients without retinopathy.

PURPOSE: To determine neuroretinal function with multifocal electroretinogram (mfERG) in diabetic subjects without retinopathy. METHODS: Multifocal electroretinogram (mfERG) was performed in 18 eyes of 18 diabetic subjects without retinopathy and 17 eyes of 17 age and gender-matched healthy control participants. Among 18 diabetic subjects, two had type 1 and 16 had type 2 diabetes. MfERG responses were averaged by the retinal areas of six concentric rings and four quadrants, and 103 retinal locations; N1-P1 amplitude and P1-implicit time were analysed. RESULTS: Average mfERG N1-P1 amplitude (in nv/deg(2)) of 103 retinal locations was 56.3 ± 17.2 (mean ± SD) in type 1 diabetic subjects, 47.2 ± 9.3 in type 2 diabetic subjects and 71.5 ± 12.7 in controls. Average P1-implicit time (in ms) was 43.0 ± 1.3 in type 1 diabetic subjects, 43.9 ± 2.3 in type 2 diabetic subjects and 41.9 ± 2.1 in controls. There was significant reduction in average N1-P1 amplitude and delay in P1-implicit time in type 2 diabetic subjects in comparison to controls. mfERG amplitude did not show any significant correlation with diabetes duration and blood sugar level. However, implicit time showed a positive correlation with diabetes duration in type 2 diabetic subjects with diabetes duration ≥5 years. CONCLUSIONS: This is the first study in a Nepalese population with diabetes using multifocal electroretinography. We present novel findings that mfERG N1-P1 amplitude is markedly reduced along with delay in P1-implicit time in type 2 diabetic subjects without retinopathy. These findings indicate that there might be significant dysfunction of inner retina before the development of diabetic retinopathy in the study population, which have higher prevalence of diabetes than the global estimate and uncontrolled blood sugar level.

Ocular morbidity among the children of squatter settlements in Kathmandu.

PURPOSE: To determine the prevalence of ocular morbidity and refractive error among the children of the squatter settlements in Kathmandu. METHODS: A cross-sectional study was carried out at five squatter settlement areas at Kathmandu, including 366 children younger than 16 years. Detailed eye examination included the visual acuity testing, cycloplegic refraction, binocular vision assessment, anterior segment examination, and posterior segment examination. Variations in age, sex, and ethnic distribution of the study population were analyzed through analysis of variance. Pearson χ test with Yate correction was used to analyze different types of ocular morbidity. Pearson correlation coefficient test was performed to correlate refractive error in the right eye and the left eye. RESULTS: Majority of children (28.9%) belonged to the age group 8 to 10 years, and most of them belonged to the Manohara settlement area (40.2%). Male-female ratio was 0.7. Uncorrected and best-corrected visual acuity of better than or equal to 6/9 in at least one eye was found in 87.9% and 99.0% children, respectively. Total ocular morbidity was observed in 33.7%. The common type of ocular morbidity was conjunctivitis (11.2%), refractive error (9.0%), and blepharitis (5.4%). Ocular morbidity was common in infants (57.9%; p = 0.043; odds ratio, 2.8) and 14- to 15-year-old children (52.8%; p = 0.002; odds ratio, 2.5). CONCLUSIONS: Ocular infection and refractive error represent the common ocular morbidity in children living in squatter settlements.

Magnitude and determinants of refractive error among school children of two districts of Kathmandu, Nepal.

PURPOSE: The purpose of this study is to assess the magnitude and determinants of refractive error among school children of Lalitpur and Bhaktapur districts in Kathmandu Valley of Nepal. MATERIALS AND METHODS: A descriptive study was carried out in 2003 in four schools; two in each district. A detailed ocular examination was conducted of all children attending these schools and that included visual acuity testing, slit lamp examination, fundus evaluation, retinoscopy, cycloplegic refraction and subjective refraction. Myopia was defined as more than -0.5 D and hypermetropia was defined as error of more than +1 D. RESULTS: A total of 2000 students of 5-16 years of age were examined. The prevalence of refractive error was 8.60% (95% confidence interval [CI] 7.37-9.83). The prevalence of myopia was 6.85% (95% CI 5.74-7.96). The best-corrected visual acuity was 6/9 or less in the eye of 12.8% children with refractive error. CONCLUSIONS: Refractive error is of public health magnitude among school children of 14-16 years of age. School screening program in countries like Nepal for early detection of treatable disease is useful to detect and correct refractive error in older students.

Methanol poisoning: ocular and neurological manifestations.

PURPOSE: The purpose of this study was to examine the effectiveness of ethanol and high-dose intravenous steroid for preserving vision in acute methanol poisoning. METHODS: Eight cases of acute methanol poisoning presented to the emergency department. Detailed physical examination including neurological assessment was performed. Detailed ocular examinations were performed including visually evoked potential and electroretinography in indicated cases. All patients had visual symptoms. Pupillary abnormality was observed in all. Edema of the optic disc and nerve fiber layer were common fundus findings. The majority of cases were treated with methylprednisolone intravenously. Ethanol was given intravenously in four cases who presented within 48 h. Hemodialysis was performed in two cases having neurological manifestations and metabolic acidosis. Sodium bicarbonate was given to four patients. Folinic acid and multivitamins were also given to all the patients based on neurological advice. RESULTS: Most of the patients showed a good response to the treatment. In 87.5% of the cases, improvements in visual acuity of at least two lines were noted in follow-up visits. CONCLUSIONS: Early presentation with prompt treatment has a significant role in preserving and improving visual acuity. Ethanol and high-dose intravenous methylprednisolone can be an alternative treatment with better visual outcome where fomepizole is unavailable.

Ocular and orbital metastases presenting as a first sign of gastric adenocarcinoma.

The authors report a case of simultaneous choroidal and orbital metastases with optic nerve involvement presenting as an initial manifestation of gastric adenocarcinoma. To our knowledge, this is the first case of its kind reported in the literature where a 60 years male presented with 6 months history of progressive painful diminution of vision in his left eye associated with inward and upward rotation of the same globe. Examination of left eye revealed displacement of the globe superomedially by an inferolateral mass with restriction of ocular motility in levoversion. Fundus examination showed exudative retinal detachment with a subretinal mass which was supported by the ocular ultrasonography. Intraocular and orbital tumour was demonstrated by CT. Endoscopic biopsy revealed adenocarcinoma of the stomach. The left orbit was exenterated and specimen was sent for histopathological examination which confirmed the presence of same metastatic tumour cells in the eye and orbit. The patient underwent chemotherapy and radiotherapy for gastric carcinoma but the patient died after 6 months.