A fungal epidemic amidst a viral pandemic: Risk factors for development of COVID-19 associated rhino-orbital-cerebral mucormycosis in India.

PURPOSE: To study the risk factors for development of COVID-19 associated rhino-orbital-cerebral mucormycosis (ROCM) during the COVID-19 pandemic in India. METHODS: Multi-centric retrospective case-control study conducted from October 2020 to May 2021. Cases comprised of consecutive patients of COVID-19-associated ROCM (CA-ROCM) presenting at the participating ophthalmic institutes. Controls comprised of COVID-19-positive or COVID-19-recovered patients who did not develop ROCM. Comparative analysis of demographic, COVID-19 infection, treatment parameters and vaccination status between cases and controls performed. Clinical and imaging features of CA-ROCM analyzed. RESULTS: There were 179 cases and 361 controls. Mean age of presentation in cases was 52.06 years (p = .001) with male predominance (69.83%, p = .000011). Active COVID-19 infection at the time of presentation of ROCM (57.54%, p < .0001), moderate to severe COVID-19 (p < .0001), steroid administration (OR 3.63, p < .00001), uncontrolled diabetes (OR 32.83, p < .00001), random blood sugar >178 mg/dl were associated with development of CA-ROCM. Vaccination showed a protective effect (p = .0049). In cases with intracranial or cavernous sinus extension there was history of steroid administration (OR 2.89, p = .024) and orbital apex involvement on imaging (OR 6.202, p = .000037) compared to those with only rhino-orbital disease. CONCLUSION: Male gender, active COVID-19 infection, moderate or severe COVID-19, uncontrolled diabetes, steroid administration during COVID-19 treatment are risk factors for developing rhino-orbital-cerebral mucormycosis. Vaccination is protective. Random blood sugar of >178 mg/dl in COVID-19 positive or recovered patients should warrant close observation and early detection of ROCM. Presence of ophthalmoplegia, blepharoptosis at first clinical presentation and orbital apex involvement on imaging are associated with intracranial extension in ROCM.

Rhino-orbital mucormycosis following COVID-19 in previously non-diabetic, immunocompetent patients.

PURPOSE: To report a series of 13 immunocompetent patients who developed new-onset uncontrolled diabetes mellitus (DM) following COVID-19 infection and presented as rhino-orbital mucormycosis (ROM). METHOD: Retrospective study. RESULTS: A total of 127 patients of COVID-19 Associated Mucormycosis (CAM) were evaluated at four centres in India. All patients underwent endoscopic sinus debridement surgery and received systemic amphotericin-B therapy. Five patients (5/13; 38.4%) received retrobulbar amphotericin-B injections. Orbital exenteration was performed in advanced orbital involvement or progression of orbital disease in spite of maximal medical therapy. In his cohort, 13/127 (10.2%) patients presented with new onset DM, where one patient had bilateral disease. The mean age was 35.9 years (range: 20-51 years) and the mean duration from diagnosis of COVID-19 to the diagnosis of mucormycosis was 14.2 days. While 7/13 (53.8%) of the patients received systemic corticosteroids during the course of their treatment for COVID-19, six patients received no steroids or immunomodulators. The mean follow-up period was 9.2 weeks (range: 3-18 weeks) following discharge. Life salvage was possible in 100% of the cases. While overall globe salvage was possible in 42.8% (6/14 eyes), the globe could be preserved in 4/5 patients who received retrobulbar amphotericin-B injections. CONCLUSIONS: Those involved in the care of COVID-19 patients should be aware about the possibility of recent-onset DM, even in patients without a history of corticosteroid therapy. Rarely, recent-onset DM following COVID-19 may present as rhino-orbital mucormycosis, which requires aggressive surgical and medical intervention.

Ocular manifestations in patients with cerebrovascular accidents in India: a cross-sectional observational study.

PURPOSE: To assess ophthalmic manifestations in patients with stroke and emphasize the importance of a formal screening for visual problems in stroke patients in hospital and rehabilitation settings. METHODS: This was a cross-sectional study of 50 newly diagnosed patients with stroke with Glasgow Coma Scale (GCS) > 8 examined within 3 days of onset. A detailed ophthalmic examination was performed for each patient including visual acuity, fields, ocular motility, slit lamp and fundus examination, line bisection tests and cranial nerve assessment. Radiological investigations were reviewed and anatomically correlated. RESULTS: A total of 50 patients (41 male and nine female) were included in the study. Mean age of the stroke cohort was 51.36 years. Twenty-nine patients (58%) had a subcortical stroke, while 42% (n = 21) patients had a cortical stroke. Nineteen patients (38%) demonstrated visual field defects. Twenty-one patients (42%) had a gaze palsy. Vertical gaze palsy (n = 8) was more common in cortical stroke, while internuclear ophthalmoplegia (n = 2), horizontal gaze palsies (n = 4) and Parinaud's syndrome (n = 1) were seen more commonly in those with subcortical stroke. Twenty-four percent (n = 12) patients had nystagmus. Twelve percent (n = 6) patients had diplopia. Thirty-eight percent (n = 19) patients had convergence insufficiency. Sixteen patients (32%) complained of visual impairment. Retinal abnormalities were seen in 58% (n = 29) of patients. CONCLUSIONS: Ophthalmic manifestations were seen in 90% of stroke survivors. Their presence in majority of the patients in our cohort suggests that earliest routine ophthalmic examination should be mandatory in all patients with acute stroke.

Patient perceptions regarding the use of smart devices for medical photography: results of a patient-based survey.

AIM: To assess patient perceptions regarding medical photography and the use of smart devices, namely mobile phones and tablets for medical photography. METHODS: A questionnaire-based survey was conducted among 280 consecutive adult patients who presented to the oculoplastics clinic at a tertiary eye care centre. The responses were tabulated and analysed. RESULTS: Of the 280 patients surveyed, 68% felt that medical photography had a positive impact on their understanding of their illnesses and 72% felt that the use of smartphones for medical photography was acceptable. Respondents below the age of 40 years were more likely to approve of the use of mobile phones for photography as compared to those over 40. Most patients (74%) preferred a doctor to be the person photographing them. While a majority approved of doctors and trainee physicians having access to their photographs, they felt non-physician healthcare personnel should not have access to clinical photographs. Also, 72% of the respondents felt that the patient's consent should be taken before using their photographs. It was noted that patient identification and breach of confidentiality could be some of the potential issues with using smart devices as cameras in the clinic. CONCLUSIONS: Clinical photography in general and, specifically, using smart devices for clinical photographs have gained acceptance among patients. The outcomes of this study may be utilized to create policy guidelines for the use of smart devices as photography tools in the clinics. The findings of this survey can also help to create standardized, uniform patient consent forms for clinical photography.

Vision Loss due to Central Retinal Artery Occlusion Following Embolization in a Case of a Giant Juvenile Nasopharyngeal Angiofibroma.

Juvenile nasopharyngeal angiofibroma (JNA) is a benign, vascular, and locally aggressive tumor that arises in the nasal cavity, extending into the nasopharynx and often in to the orbit. It may rarely present to the ophthalmologist with proptosis and optic neuropathy. Preoperative embolization of JNA is done before surgical resection. In this communication, the authors report a rare occurrence of ipsilateral central retinal artery occlusion (CRAO) following embolization with polyvinyl alcohol in a 13-year-old boy with right-sided JNA. Retrospective review of the angiograms pointed out to a suspicious communication between the external carotid artery and the ophthalmic vessels. Pre-embolization detailed study of the angiograms is necessary to avoid such devastating complications. Although rare, vision loss is a possible complication arising from embolization of nasopharyngeal and intracranial tumors, and all patients undergoing these procedures should be informed of the risk of visual loss because it has a lasting impact on the quality of life.

Transcutaneous endoscopic orbital surgery: a less morbid alternative to lateral orbitotomy.

BACKGROUND: Retrobulbar lesions of the orbit situated lateral to the optic nerve are difficult to access. In this article, the authors would like to present a new perspective to approach these lesions where the goals of surgery are met with minimal complications. METHODS: A retrospective analysis of patients' charts was performed. RESULTS: For approaching retrobulbar lesions an endoscopic technique was developed. Four patients (2 male and 2 female patients) presenting with retrobulbar lesions lateral to the optic nerve have been included in this study. Two patients underwent endoscopic drainage for orbital abscess and two patients were successfully biopsied endoscopically. No intra-operative complications were noted. Open procedures such as lateral orbitotomy were avoided in all the cases. CONCLUSION: Transcutaneous orbital endoscopy is a safe and a versatile technique to approach retrobulbar lesions lateral to the optic nerve. It can be used as an effective alternative to lateral orbitotomy for well selected cases. One can obtain adequate material for histopathological examination and also drain deep-seated orbital abscess using this technique. It would be possible with increasing experience to use this technique for extended applications.

Simultaneous Bilateral Orbital Cellulitis With Meningitis Caused by Methicillin-Resistant Staphylococcus aureus in an Immunocompetent Infant.

The authors report a rare case of fulminant bilateral orbital cellulitis caused by methicillin-resistant Staphylococcus aureus associated with meninigitis in a neonate. The clinical, laboratory, photographic, and radiological records are reviewed. A 17-day-old female infant presented with swelling over both upper eyelids and proptosis in both eyes. Computed tomography showed mutli-loculated abscesses within both orbits. Eyelid swelling and proptosis resolved following transcutaneous aspiration of the purulent material. Cerebrospinal fluid examination yielded Gram-positive cocci, which on culture and polymerase chain reaction testing was identified as methicillin-resistant Staphylococcus aureus. The infant received an extended course of antibiotics. At 12 months of follow-up, the infant was systemically normal with normal milestones, complete ocular movements, and no neurological sequelae. This case highlights the need for cerebrospinal fluid analysis in bilateral orbital cellulitis, even in cases not exhibiting central nervous system involvement. Aggressive medical and surgical treatment is needed in bilateral orbital cellulitis. [J Pediatr Ophthalmol Strabismus. 2020;57:e34-e37.].

Orbital Exenteration in Rhino-Orbito-Cerebral Mucormycosis: A Prospective Analytical Study with Scoring System.

Mucormycosis is an uncommon, rapidly progressive, angio-invasive, commonly fatal, opportunistic fungal infection. The most critical decision in the management of rhinoorbital mucormycosis is whether the orbit should be exenterated. (1) To layout the indications of orbital exenteration in patients with rhino-orbito-cerebral mucormycosis. (2) To devise a scoring system that predicts the stage at which the exenteration needs to be carried out. A scoring system was devised by a team of experienced Otorhinolaryngologists and Ophthalmologists from prior experience in managing mucormycosis. All patients of mucormycosis visiting our hospital were admitted and included in the study. A total of 15 patients were included. The scoring system is based on 3 main criteria, namely: (1) clinical signs and symptoms. (2) Direct and Indirect Ophthalmoscopy. (3) Imaging. The Sion Hospital Scoring System is an accurate and promising measure to solve the dilemma that is associated with orbital exenteration in orbito-rhino-cerebral mucormycosis.

Salmonella Typhi Associated Endogenous Endophthalmitis: A Case Report and a Review of Literature.

AIM: To report a rare case of Salmonella typhi associated endogenous endophthalmitis in an immunocompetent male and to review the available literature. METHODS: Retrospective chart review. RESULTS: A 28-year-old immunocompetent male presented with a 3-day-old history of pain, redness and diminished vision in his left eye. Conjunctival chemosis, corneal haze, and hypopyon were noted and yellowish exudates filled the vitreous cavity. A detailed elicitation of history revealed that patient had been treated for enteric fever that presented with diarrhea and fever, two weeks prior to current presentation. Blood and vitreous cultures grew Gram negative bacilli, identified as S. typhi. Despite intensive intravitreal and systemic antibiotic therapy, an evisceration had to be performed. CONCLUSIONS: Endogenous endophthalmitis can be one of the rare sequelae of enteric fever and may present in the acute and relapsing phases and often times have a rapidly fulminant course with poor visual outcomes.

Actinomycetes canaliculitis complicating congenital nasolacrimal duct obstruction in an infant.

Actinomyces israelii is a Gram-positive anaerobic organism commonly associated with canaliculitis in adults. Pediatric canaliculitis is relatively rare, especially in infancy. We report the case of an 11-month-old boy who presented with co-existing canaliculitis and congenital nasolacrimal obstruction. The presenting signs included epiphora, discharge, conjunctival congestion, and matting of lashes. On examination, punctual pouting, regurgitation, and yellow canaliculiths were noted. A punctoplasty and canalicular curettage were performed along with nasolacrimal probing. Microbiological tests confirmed the organisms to be A. israelii. We discuss the clinical features and management of Actinomyces-associated canaliculitis and review the available literature on pediatric canaliculitis.

Nontraumatic subperiosteal orbital hemorrhage following upper gastrointestinal endoscopy.

Subperiosteal hemorrhages are typically the result of blunt orbital or facial trauma. Nontraumatic subperiosteal hemorrhages are uncommon and are usually attributed to increase in central venous pressure and bleeding disorders. Here, we report the case of a 38-year-old female who underwent an upper gastrointestinal (GI) endoscopy and developed bilateral nontraumatic subperiosteal hemorrhages that resolved with conservative treatment. Here, we discuss the source of bleeding and the mechanisms for the occurrence of orbital subperiosteal bleeds. GI surgeons and ophthalmologists should be sensitive to the possibility that orbital hemorrhage that can occur following endoscopy, especially when retching or gagging occurs during the procedure.

Giant Perivascular Epithelioid Cell Tumor of the Orbit: A Clinicopathological Analysis and Review of the Literature.

AIM: To describe and review the clinical, radiological, and histopathological characteristics of an orbital perivascular epithelioid cell tumor (PEComa). METHODS: A systematic review of clinical records, radiological investigations, microscopic features, and immunohistochemical characteristics was done. RESULTS: A 9-year-old female child presented with a year-long history of a large orbital mass associated with painless, progressive proptosis of the right eye. Radiologically, a well-defined orbital mass was seen with no intracranial extension. Excision was performed and histopathological examination showed uniform epithelioid cells in nests separated by thin fibrovascular septae. The tumor cells stained positively for Human Melanoma Black-45, but neg-atively for desmin, S-100, smooth muscle actin, MyoD1, microphthalmia-associated transcription factor, vimentin, CD10, CD31, and CD34 with a low proliferation index of 5-7%. Based on the tumor's morphological and immuno-histochemical characteristics, a diagnosis of giant orbital PEComa was made. No recurrence was seen at the last follow-up. CONCLUSIONS: PEComas are uncommon mesenchymal neoplasms that have typical histological features, with an immunohistochemical profile of negativity for epithelial markers and positivity for melanocytic markers. For benign PEComas, complete excision is advised. However, since PEComas elsewhere in the body have been known to be malignant, a close follow-up of such cases is recommended.

Orbital Cellulitis with Endogenous Panophthalmitis Caused by Methicillin-Sensitive Staphylococcus aureus in Pregnancy.

Orbital cellulitis along with panophthalmitis is uncommon. The causes are usually trauma-related or endogenous. The prognosis in terms of globe salvage is very poor, with most cases usually requiring enucleation or evisceration of the affected eye. Immunosuppression in some form is usually present, which accounts for the aggressive course of the infection. In this communication, we report on a case in a 25-year-old female, who in the second trimester of pregnancy had developed orbital cellulitis and panophthalmitis caused by methicillin-sensitive Staphylococcus aureus (MSSA), with the primary source of infection being cellulitis on her forearm following intravenous therapy for severe anemia. Despite intensive intravenous and topical antibiotics, she required an evisceration of the eye. However, the pregnancy continued uneventfully with the delivery of a full-term, healthy infant. Bacteremia, although rare in pregnancy, can cause endogenous panophthalmitis and orbital cellulitis, especially in a background of immunosuppresssion.

An Unusual Eyelid Mass of Cysticercosis: A Twist in the Tale.

Cysticercosis is a parasitic infestation caused by the larval form of the tapeworm, Taenia solium (T. solium). The common sites for cysticerosis include the brain, eyes, and skeletal muscle. Ocular or adnexal involvement is commonly seen with the commonest ophthalmic site being subretinal space and the vitreous cavity. However, only a handful of cases of eyelid cysticercosis have been reported in the past. We report a rare and unusual case of isolated eyelid cysticercosis in a middle-aged woman masquerading as an asymptomatic slowly growing subcutaneous painless mass in the left eyelid which was presumed to be a benign skin mass, a cyst of appendageal origin such as an epidermoid cyst. This case highlights the ubiquitous nature of cysticercosis in tropical countries and the need for a high degree of suspicion while surgically treating subcutaneous masses. We would additionally emphasize the need to rule out neurocysticercosis in such cases.

Vincristine-Induced Neuropathy Presenting as Ptosis and Ophthalmoplegia in a 2-Year-Old Boy.

Vincristine is used in the treatment of leukemias, solid tumors, and lymphomas. A case of a 2-year-old boy undergoing treatment for leukemia who developed sudden onset bilateral ptosis and ophthalmoplegia along with generalized neuropathy due to vincristine's neurotoxic effects is presented. He was successfully treated with pyridoxine and pyridostigmine. The possible mechanisms of action and the treatment for vincristine-induced neuropathy are discussed. Prompt treatment and close follow-up is needed, especially in children because prolonged ptosis and motility restriction may have a profound effect on a child's visual function.