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.

Turbulent Flow in a Cavernous Sinus Lesion: Does It Suggest Something?

A 14-year-old boy who had been complaining of double vision for the previous month was referred for neuro-ophthalmological evaluation. He was carrying a diagnosis of a cavernous sinus haemangioma causing a right VIth nerve palsy, based on imaging elsewhere. He reported having a boil at the angle of his mouth, which was associated with left-sided facial cellulitis, two weeks before the onset of the diplopia. His blood investigations showed a leukocytosis with elevated inflammatory markers. Re-evaluation of the magnetic resonance imaging suggested a sac-like out-pouching in the intracavernous part of the right internal carotid artery with differential intensity suggestive of turbulent flow. On the basis of the clinico-radiological findings, a diagnosis of mycotic aneurysm of the cavernous sinus part of internal carotid artery was made. A high index of suspicion is required to detect this rare clinical entity, which is associated with a potentially catastrophic clinical course.

Effect of Prone Positioning on Intraocular Pressure in Patients With Acute Respiratory Distress Syndrome.

OBJECTIVES: To evaluate the effect of prolonged duration of prone position (with head laterally rotated) on intraocular pressure in acute respiratory distress syndrome patients. DESIGN: Prospective observational study. SETTING: University hospital ICU. PATIENTS: Twenty-five acute respiratory distress syndrome patients, age 60 years (51-67 yr), Sequential Organ Failure Assessment score 10 (10-12), PaO2/FIO2 ratio of 90 (65-120), and all in septic shock. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Intraocular pressure (in mm Hg) measured by hand-held applanation tonometer, at different time points. Before prone (in both eyes): at 30-45° head-end elevation position (THE pre-prone), in supine position just before turning prone (Tsupine pre-prone); during prone (in nondependent eye): at 10 minutes (T10 prone), 30 minutes (T30 prone), and at just before end of prone session (Tend-prone). After end of prone session (both eyes): at 5 minutes (T5 supine post-prone), 10 minutes (T10 HE post-prone), 15 minutes (T15 HE post-prone), and 30 minutes (T30 HE post-prone). Median duration of prone position was 14 hours (12-18 hr). Median intraocular pressure increased significantly (p ≤ 0.001) in both eyes. In dependent eye, from 15 (12-19) at THE pre-prone to 24, 21, 19, and 16 at T5 supine post-prone, T10 HE post-prone, T15 HE post-prone, and T30 HE post-prone respectively, whereas in nondependent eye from 14 (12-18.5) at THE pre-prone to 23, 25, 32, 25, 22, 20, and 17 at T10 prone, T30 prone, Tend-prone, T5 supine post-prone, T10 HE post-prone, T15 HE post-prone, and T30 HE post-prone respectively. Bland-Altman plot analysis showed significant linear relationship (r = 0.789; p ≤ 0.001) with good agreement between rise in mean intraocular pressure of the both eyes (dependent eye and nondependent eye) with their paired differences after the end of different duration of prone session (T5 supine post-prone). CONCLUSIONS: There is significant increase in intraocular pressure due to prone positioning among acute respiratory distress syndrome patients. Intraocular pressure increases as early as 10 minutes after proning, with increasing trend during prone position, which persisted even at 30 minutes after the end of post prone session although with decreasing trend.

A case report of rim enhancing lesion at the orbital apex.

We report a case of partial third nerve palsy resulting from a cystic lesion located at the orbital apex. Imaging was suggestive of cystic schwanomma but histopathology of the lesion confirmed epidermoid cyst, which is a rare tumour of the orbit.

Lung carcinoma presenting as monocular painless blindness.

To discuss a very rare presentation of lung malignancy which results in visual disturbance as first and only clinical manifestation. Case report. We report a case of otherwise asymptomatic 32-year-old, nonsmoker female presenting with painless loss of vision in the right eye and photophobia in the left eye, owing to secondaries in choroid from lung carcinoma. Patient was worked up after admission in our hospital to ascertain the cause of blindness and subsequently revealed lung malignancy with widespread metastasis involving multiple organ systems. Despite widespread malignant involvement patient was completely asymptomatic and active except for visual disturbances. This case further emphasized the necessity of prompt and priority-based evaluation of patients for lung carcinoma whenever doubtful intraocular lesions are noted, regardless of age or smoking status. It seems that these cases represent a distinct subset of lung malignancy.

Malignant Hypertension and the Role of Ophthalmologists: A Review Article.

Malignant hypertension (MHT) is a sudden and severe increase in systemic blood pressure (BP) associated with advanced bilateral retinopathy. It comes under a broader term, called hypertensive emergency, where an acute rise in BP results in end-organ damage. The condition usually requires hospital admission and intensive care management. Although there are lots of sophisticated machines and laboratory tests present to diagnose various organ damage, the role of ophthalmologists will still be at the top. A record of the acute rise of BP to a defining level and simple ophthalmoscopy with high clinical suspicion can save a patient's life and preserve target organ function by timely referral. So, every ophthalmologist should be aware of this dangerous condition. In this review, we have tried to compile all the current knowledge regarding malignant hypertension that an ophthalmologist may require in day-to-day practice.

Metastasis to optic nerve presenting as ill-fitting prosthesis.

We report a rare case of metastatic adenocarcinoma of lung in anophthalmic socket, which presented as painful and difficult prosthetic wear long after an uneventful enucleation. Bulge in the socket indicated amputation neuroma, a rarity in itself; but further evaluation concealed a yet silent pulmonary mass. No case report so far describes metastatic mass in an anophthalmic socket and we describe first case of unknown lung malignancy presenting as ill-fitting prosthesis.

Corneal biomechanical properties in patients with kidney transplant.

PURPOSE: The purpose of the study was to evaluate the corneal biomechanical properties in patients post kidney transplant and to compare them with healthy age-matched control. MATERIALS AND METHODS: In this cross-sectional study, 68 patients with kidney transplant (study group) and 68 healthy individuals (control group) were analyzed with ocular response analyzer measurements. Only the right eye of each participant was assessed for corneal hysteresis (CH), corneal resistance factor (CRF), corneal-compensated intraocular pressure (IOPcc), and Goldmann-correlated intraocular pressure (IOPg). RESULTS: The mean CH in the study group was 9.70 ± 1.62 mmHg which was significantly lower than the control group with the mean CH of 10.60 ± 1.49 mmHg (P = 0.001). The mean IOPcc was 18.17 ± 4.00 mmHg and 16.00 ± 3.94 mmHg in the study and control groups, respectively (P = 0.002). CRF and IOPg were not significantly different between groups. CONCLUSION: CH and IOPccare altered in kidney transplant patients.

Segmented retinal analysis in pituitary adenoma with chiasmal compression: A prospective comparative study.

PURPOSE: The aim of this study was to determine the alteration in ganglion cell complex and its relationship with retinal nerve fiber layer (RNFL) thickness as measured by spectral-domain optical coherence tomography (OCT) in pituitary adenoma cases and also its correlation with visual field (VF). METHODS: This is a prospective comparative study wherein detailed neuro-ophthalmic examination including perimetry, RNFL and ganglion cell layer inner plexiform layer (GCL-IPL) thickness were measured preoperatively in the cases of pituitary adenoma with chiasmal compression with visual symptoms and field changes who were planned for neuro-surgical intervention. These parameters were repeated 1 year after the surgery. GCL-IPL, RNFL parameters were compared with controls and were correlated with VF mean deviation (MD). The diagnostic power of GCL-IPL was tested using the receiver operating characteristic (ROC) curve. Healthy age and sex-matched controls without any ocular and systemic abnormality were taken for comparison. RESULTS: Twenty-four patients qualified the inclusion criteria. A significant thinning of GCL-IPL (P = 0.002) and RNFL (P = 0.039) was noticed in the pituitary adenoma group. GCL-IPL (r = 0.780 P < 0.001) and RNFL (r = 0.669, P < 0.001) were significantly correlated with the MD. The ROC curve values of GCL-IPL were 0.859 (95% confidence interval 0.744% to 0.973) and of RNFL were 0.731 (95% confidence interval 0.585-0.877). The diagnostic ability of GCL-IPL was more as compared to the RNFL analysis, although it was statistically insignificant (P = 0.122). CONCLUSION: GCL-IPL measurements on the OCT are a sensitive tool to detect early anterior visual pathway changes in chiasmal compression for pituitary adenoma patients.

Tubulointerstitial nephritis and uveitis syndrome: Our experience.

Tubulointerstitial nephritis and uveitis (TINU) syndrome is a distinct oculorenal disorder of immune origin and accounts for some cases of unexplained recurrent uveitis. We report three cases of TINU syndrome, one of which had primarily come to us with uveitis. It is the occurrence of tubulointerstitial nephritis and uveitis in a patient in the absence of other systemic diseases that can cause either interstitial nephritis or uveitis. TINU syndrome is a diagnosis of exclusion. Our aim in reporting these cases is to highlight the association of nephritis and uveitis, which together form a distinct clinical disorder called the TINU syndrome.

Limbal schwannoma: Clinicopathological study of a case with review of literature.

Schwannomas involving the perilimbal conjunctiva is an extremely rare clinical entity and has been reported scantily in literature. In this case, a 27-year-old healthy female presented with a pinkish smooth globular mass involving the limbus in the superonasal quadrant of the left eye. The mass was completely excised and histopathology revealed an encapsulated tumor, with cells displaying elongated nuclei, bland chromatin, and few Verocay bodies with palisaded nuclei, suggestive of schwannoma. Immunohistochemistry showed strong S100 positivity. This case thus highlights schwannoma as a differential diagnosis of limbal masses.

Mycotic Aneurysm of Intracavernous Internal Carotid Artery Presenting as Cavernous Sinus Syndrome.

Mycotic intracranial aneurysms are infectious aneurysms accounting for 0.7%-6.5% of all intracranial aneurysms and are most commonly located in distal branches of the middle cerebral arteries, particularly at the bifurcation area. They are caused by weakening of the vessel wall secondary to infection of a segment of the artery that can be endovascular as in infective endocarditis or extravascular as in meningitis or cavernous sinus thrombophlebitis. The rare occurrence of the mycotic cavernous internal carotid artery aneurysm, its variable clinical picture and limited knowledge of its natural course is a challenge for both diagnosis and management.

Effect of Long-term Oral Steroids on Intraocular Pressure in Children With Autoimmune Hepatitis: a Prospective Cohort Study.

OBJECTIVE: Topical corticosteroids are known to cause raised intraocular pressure (IOP). However, there is a scarcity of literature regarding systemic steroids-induced raised IOP in children. The authors aimed to evaluate the IOP in children with autoimmune hepatitis (AIH) receiving oral prednisone. METHODS: In this prospective study, children (1 to 18 y) with newly diagnosed AIH who received oral prednisone (July 2016 to December 2017) were included. Comprehensive ophthalmic check-up, including visual acuity, IOP, slit-lamp, and fundus examinations were done before and at 1, 3, and 6 months of follow-up. IOP ≥20 mm Hg was considered raised IOP. Symptomatic raised IOP patients were managed with antiglaucoma medication with a tapering dose of prednisone. RESULTS: A total of 33 children (19 boys) with a median age of 11 (3 to 18) years were analyzed. Raised IOP was observed in 20 (61%) children (19 were moderate and 1 was high responder) at 1 month, 8 (24%) at 3 months, and 1 (3%) at 6 months of treatment. Patients who developed raised IOP had a more severe liver disease in terms of decompensation and low albumin and high pediatric end-stage liver disease scores at presentation. There was no correlation between IOP and starting and cumulative dose of steroids. On multivariate analysis, decompensation at presentation was significantly associated with raised IOP (P<0.001; odds ratio, 30; 95% confidence interval, 4.2-210.6). Raised IOP returned to normal with antiglaucoma medication along with prednisone tapering in all except one. CONCLUSIONS: Systemic corticosteroids in children with AIH carry a risk for IOP elevation, especially in decompensated liver disease. A periodic ophthalmic check-up is necessary for early recognition and intervention before irreversible vision loss.

Ethambutol-induced optic neuropathy in renal disorder: a clinico-electrophysiological study.

OBJECTIVE: To report the spectrum of ethambutol induced optic neuropathy in a group of renal patients with tuberculosis and the role of visual evoked response (VER) in evaluating this disorder. METHODS: Twenty-three renal patients who were started on ethambutol as a part of anti-tubercular treatment for tuberculosis in India, were divided into 4 groups based on glomerular filtration rate (GFR): group 1-chronic kidney disease (CKD) with GFR < 10 mL/min; group 2-CKD with GFR 10-30 mL/min; group 3-GFR > 30 ≤ 60 mL/min; and group 4-GFR > 60 < 90 mL/min. Detailed clinical and electrophysiological (VER) examinations were carried out in all patients before starting the treatment with ethambutol and at a 3-month interval. Twenty healthy subjects formed the control group. RESULTS: Ethambutol optic neuropathy developed in 6 (26%) patients with higher incidence (40%) in end-stage renal disease (group 1: CKD on dialysis). Vision was recovered in 4 cases on stoppage of ethambutol, whereas 2 patients (group 1: CKD on dialysis) developed bilateral severe irreversible visual loss and also had associated hepatic dysfunction. Three patients of ethambutol optic neuropathy showed increased latency in VER recording prior to visual loss and 1 patient showed demyelinating lesions in both optic nerves and optic radiation. CONCLUSIONS: Ethambutol should be avoided in renal disorder patients in view of the high incidence of toxic optic neuropathy. Follow-up VER can detect sub-clinical ethambutol toxicity and would be useful for early diagnosis of optic neuropathy.

Encephalocele presenting as lower lid swelling: A rare case report.

Encephalocele is a rare congenital abnormality characterized by abnormal protrusion of brain and meninges through an opening in the skull. We report an 8-year-old girl who presented with a swelling in the right lower lid for the last 6 years. In her infancy, she had undergone surgery for a very small swelling located in the right nasolacrimal area. On further clinicoradiological evaluation, anterior encephalocele was diagnosed. This case highlights the uncommon site of anterior encephalocele; misdiagnosis and mismanagement of which could result in dreaded complications such as meningitis and cerebrospinal fluid leaking fistula formation.