Molecular characterization of coxsackievirus A24 variants isolated from an outbreak of acute hemorrhagic conjunctivitis.

PURPOSE: Acute Hemorrhagic conjunctivitis (AHC) is associated with CVA24v. Recently there was a severe outbreak of conjunctivitis in months of July and August 2023 in India. This study emphasizes the identification of the distinct mutations in the CVA24v strains, which were isolated during the AHC outbreak and could have potentially played a role in the high transmission of AHC in India during the 2023 outbreak. METHODS: A total of 71 conjunctivitis patients aged 1-75 years comprising 47 males and 24 females who attended Ophthalmology department of a tertiary care hospital of easternIndia were studied.RNA was extracted from all conjunctival swab samples and converted into cDNA. Subsequently, the viral 5' UTR was amplified and the PCR positive samples were subjected to sequencing. The newly isolated viral 5' UTR sequences were aligned with other worldwide sequences using the Clustal W tool to conduct mutational analysis. A phylogenetic tree was built using the MEGA software for viral genotype identification. RESULTS: All of the current outbreak strains belonged to genotype IV of CVA24v. The present outbreak strains formed a distinct clade in the phylogenetic tree and were different from previously reported Indian strains. Two persistent mutations, specifically in domain IV (T213C) and domain V (C475T), were exclusively detected within the internal ribosome entry site (IRES) of the 5' UTR of the current strains causing the outbreak. These two alterations have previously been shown to impact the virulence of another enterovirus (CV B3), but they have not been described in CVA24v until now. CONCLUSION: Finding of the present study highlights the possibility and the significance of the aforementioned two mutations in enhancing the transmissibility of the newer CVA24v strains. Hence, these two distinct mutations should be investigated further for developing antiviral therapies to combat future AHC outbreaks associated with CVA24v.

Double peak sign on ultrasonography: A new prognostic marker before surgery for white cataract.

A mature, hypermature, or white cataract needs posterior segment evaluation before surgery for prognostification. Ultrasonography is the preferred method for this. White cataract or intumescent cataract risks intraoperative capsulorhexis running out leading to devastating complications due to high intralenticular pressure. Altghough sligh-lamp examination before surgery can gives clue regarding fluid pockets under anterior capsule in these types of cataract, fluid in posterior compartment of lens can be detected by ultrasonography. The author here described a new sign, the double peak sign which can predict the high intra-lenticular pressure especially in posterior compartment of the lens. So if it detected before surgery, all precautions can be taken during surgery to prevent complications. The A-scan overlay on the B-scan in ultrasonography can detect the hypoechoic area corresponding to the lequified cortex in between solid lens nucleus and posterior capsule, so giving rise to the double peak sign which is described here as an innovation.

A double-blinded study for quantifiable assessment of the diagnostic accuracy of AI tool "ADVEN-i" in identifying diseased fundus images including diabetic retinopathy on a retrospective data.

PURPOSE: To quantifiably assess the diagnostic accuracy of Adven-I, a proprietary artificial intelligence (AI)-driven diagnostic system that automatically detects diseases from fundus images. The purpose is to quantify the performance of Adven-i in differentiating a nonreferable (within normal limits) image from a referable (diseased fundus) image and further segregating diabetic retinopathy (DR) from the rest of the abnormalities (non-DR) encompassing the wide spectrum of abnormal pathologies. The assessment is carried out in comparison to manual reading as the reference gold standard. Adven-i is the only AI system classifying retinal abnormalities into DR and non-DR classes separately, apart from predicting nonreferable fundus, while most existing systems classify fundus images into referable and nonreferable DR. METHODS: The double-blinded study was conducted on retrospective data collected over the course of a year in the ophthalmology outpatient department (OPD) at a top Tier II eyecare hospital in Chandigarh, India. Three vitreoretina specialists who were blinded to one another read the images. The ground-truth was generated on the basis of majority agreement among the readers. An arbitrator's decision was regarded final if all three readers disagreed. RESULTS: 2261 fundus images were analyzed by Adven-i. The sensitivity and specificity of Adven-i in diagnosing images with abnormalities were 95.12% and 85.77%, respectively, and for segregating DR from rest of the retinal abnormalities were 91.87% and 85.12%, respectively. CONCLUSIONS AND RELEVANCE: Adven-i shows definite promise in automated screening for early diagnosis of referable fundus images including DR. Adven-i can be adopted to scale for mass screening in resource-limited settings.

Study of rhino-orbital-cerebral mucormycosis and its correlates during COVID-19 pandemic in a tertiary eye care institute of central India.

PURPOSE: To evaluate factors associated with the occurrence of ROCM in COVID-19 patients and to compare its related parameters and outcomes between active and recovered COVID-19 groups. METHODS: A total of 35 patients of ROCM associated with COVID-19 (active and post-COVID-19) were included. This is an ambispective study with retrospective medical records review for COVID-19 analysis and prospective assessments of ROCM-associated COVID-19 during the second wave of the COVID-19 pandemic. The demographic data, clinical parameters, and outcome were recorded on MS excel sheet, and various parameters were compared between active and recovered COVID-19 groups. RESULTS: ROCM in recovered COVID-19 group was higher (57.1%) as compared to active COVID-19 (42.9%) (P = 1.00). High occurrence of ROCM was seen in those who had a history of hospitalization due to severity of COVID-19 (n 33, 94.28%), oxygen support (77.14), and received systemic steroids (82.9%). The most common comorbidity was diabetes mellitus (82.9%), and new-onset hyperglycemia was noticed in 17.1% of patients. Exenteration (28.6%) was performed in severe cases who had stage IV ROCM, bilateral, and CNS involvement (RR = 7.2, 95% CI: 2.91 to 18.00). The risk of globe exenteration was 1.35 (0.7-2.29) times higher in recovered COVID-19 group, and mortality was 1.76 (0.72-3.36) times higher in active COVID-19 group. CONCLUSION: Monitored use of systemic steroids and the prompt management of hyperglycemia in COVID-19 patients are important factors for favorable outcomes with reference to globe salvage and life-saving in ROCM associated with COVID-19. Even recovered COVID-19 patients should be observed for persistent hyperglycemia and occurrence of ROCM.

Eyewash with balanced salt solution after intravitreal methotrexate injection in a case of vitreoretinal lymphoma: a simple but effective way to prevent ocular surface toxicity.

Intravitreal methotrexate injection (400 µg/0.1 mL) is the current mainstay for managing vitreoretinal lymphoma. Various complications associated with intravitreal methotrexate are cataract, keratopathy, maculopathy, sterile endophthalmitis, optic atrophy, vitreous haemorrhage, etc. The most common adverse effect of intravitreal methotrexate is keratopathy occurring in more than half of cases. The severity may range from diffuse punctate keratopathy to severe epitheliopathy leading to photophobia, pain, visual blurring, epiphora, etc. This may become a reason for reduced compliance with treatment. The management of these complications includes oral folic acid, topical folinic acid supplementations and reduced frequency or cessation of methotrexate intravitreal injections. Here, we report a simple method of eyewash in a large amount of balanced salt solution after the intravitreal injection procedure to reduce the severity of keratopathy, which helped the patient tolerate the treatment.

Papillomacular bundle sparing versus conventional internal limiting membrane peeling for idiopathic macular hole ≤400 µm.

Purpose: To compare the outcomes of papillomacular bundle (PMB) sparing internal limiting membrane (ILM) peeling (group LP) and conventional ILM peeling (group CP) for treatment of idiopathic macular hole (MH) of ≤400 µm. Methods: Fifteen eyes were included in each group. In group CP, conventional 360° peeling was done, while in group LP, ILM was spared over PMB. The changes in peripapillary retinal nerve fiber layer (pRNFL) thickness and ganglion cell-inner plexiform layer (GC-IPL) thickness were analyzed at 3 months. Results: MH was closed in all with comparable visual improvement. Postoperatively, retinal nerve fiber layer (RNFL) was significantly thinner in the temporal quadrant in group CP. GC-IPL was significantly thinner in the temporal quadrants in group LP, whereas it was comparable in group CP. Conclusion: PMB sparing ILM peeling is comparable to conventional ILM peeling in terms of closure rate and visual gain, with the advantage of less retinal damage at 3 months.

Paracentral Acute Middle Maculopathy As the Presenting Sign of Ischemic Cardiomyopathy.

Paracentral acute middle maculopathy (PAMM) is a type of ischemic maculopathy affecting intermediate and deep retinal capillary plexuses. A typical presentation is acute onset scotoma with or without vision loss. It is characterized by greyish-white parafoveal lesions. Sometimes very subtle lesions can be missed on clinical examination. The main diagnostic modality is spectral domain optical coherence tomography (SD-OCT) wherein focal or multifocal lesions are seen as bands of hyperreflectivity in the inner nuclear and outer plexiform layers. This entity can be associated with systemic microvascular diseases. Here, we report an interesting case of PAMM as the only presenting sign in a patient with ischemic cardiomyopathy, highlighting the necessity for a thorough systemic examination in such patients.

Rare Presentation of Apocrine Hidrocystoma Along the Nasolacrimal Duct.

Hidrocystomas are rare benign cystic tumors of the sweat glands, with no cases of hidrocystoma of nasolacrimal duct previously reported. We present a case of a 28-year-old female with no prior significant medical history presenting with an enlarging mass medial to her right lower eyelid for 2 years. Computed tomography scan showed nodular soft tissue in the middle part of the right nasolacrimal duct. Following complete excision of the cyst, histopathology reported an apocrine hidrocystoma, which is very rare.

Ocular manifestations in moderate-to-severe psoriasis in India: A prospective observational study.

Purpose: Ocular manifestations in psoriasis are due to direct eye involvement with psoriatic plaques or psoriasis-related, immune-mediated inflammatory processes. The commonly reported pathologies are blepharitis, conjunctivitis, keratitis, dry eyes, and uveitis. Limited data is available on the ocular findings in psoriasis patients in India. In this study, we evaluated various ocular changes associated with moderate-to-severe psoriasis. Methods: In this prospective cohort study, treatment-naive psoriasis patients with Psoriasis Area Severity Index (PASI) score of more than 10 were included. The Ocular Surface Disease Index (OSDI) score, Schirmer's score, tear film breakup time (TBUT), corneal and conjunctival staining score, and meibomian gland dysfunction score were noted. All these parameters were re-evaluated at 8 weeks of follow-up after systemic treatment. Results: Sixty-eight patients were enrolled in the study. The most common ocular pathologies observed in this study were tarsal hyperemia and anterior blepharitis in 128 (94.1%) and 64 (47%) eyes, respectively. Mild, moderate, and severe dry eyes were seen in 26 (19.1%), 14 (10.2%), and 34 (25%) eyes, respectively. Thirty-nine (57.3%) patients complained of significant difficulty watching television or digital screen. In 21 patients evaluated on follow-up at 8 weeks, cornea and conjunctiva's ocular surface staining score increased and TBUT decreased significantly. Conclusion: The most common ocular pathologies observed in this study were anterior blepharitis and moderate dry eye, which significantly affected most patients' daily routines. Screening patients with greater severity of psoriasis would help in early management of such problems.

Axial myopia, a protective factor for diabetic retinopathy-role of vascular endothelial growth factor.

Long axial length is one of the ocular protective factors in development of diabetic retinopathy (DR). In this study we examined the effect of axial length (AL) on aqueous humor vascular endothelial growth factor (VEGF) levels in patients with diabetes mellitus with or without DR. Forty-eight eyes of 48 participants were divided into three groups of 16 each. Group A consisted of non-diabetic patients, Group B had diabetic patients without DR, and Group C had diabetic patients with treatment-naive non-proliferative DR (NPDR). The groups were further subdivided based on axial lengths i.e., AL ≤ 23.30 mm (A1, B1, C1) and AL > 23.30 mm (A2, B2, C2). Undiluted aqueous humor was obtained during cataract surgery to measure the VEGF levels. We observed significant decrease in VEGF concentration in patients with AL ≥ 23.30 mm as compared with AL ≤ 23.30 mm in non-diabetic as well as diabetic patients. As the eye elongates, there is less secretion of VEGF in non-diabetics as well in diabetics with or without DR. Our findings strengthened the concept that an increase in AL leads to less VEGF in diabetic eyes, thus leading to less severe DR changes.

Pretreatment with systemic corticosteroid can mask early symptoms of hypersensitivity reaction to hyaluronidase following peribulbar block.

Hyaluronidase is a hydrolytic enzyme that helps in breaking down hyaluronic acid, a component of the extracellular tissue matrix, thereby facilitating the dispersion of local anaesthetic drugs through tissue planes. It is a key component in peribulbar anaesthesia for ocular surgeries. Allergic response to hyaluronidase is relatively rare but a potentially vision-threatening complication. A preoperative intradermal hypersensitivity test is useful to detect such cases and avoid potential complications. Here we report a case of hypersensitivity reaction to hyaluronidase after peribulbar anaesthesia for cataract surgery where an intradermal hypersensitivity test was falsely negative, and presentation was delayed due to the use of preoperative systemic corticosteroids. However, correct, and timely diagnosis and treatment saved the eye from permanent vision loss.

Microscope-Integrated Optical Coherence Tomography-Guided Autologous Full-Thickness Neurosensory Retinal Autograft for Large Macular Hole-Related Total Retinal Detachment.

PURPOSE: To evaluate the feasibility and utility of microscope-integrated optical coherence tomography in patients undergoing full-thickness neurosensory retinal autograft for refractory macular hole (MH)-associated retinal detachment. METHODS: We analyzed two eyes of two patients who had undergone a neurosensory retinal autograft for large MH associated retinal detachment. Both cases had microscope-integrated optical coherence tomography-guided placement and sizing of the retinal autograft. Time taken for obtaining microscope-integrated optical coherence tomography images, morphology of the retinal autograft (intraoperative and postoperative), and anatomic and functional outcomes were noted. RESULTS: The first case had optic disc pit-related maculopathy with a large MH and total retinal detachment. She had undergone a vitrectomy with internal limiting membrane peeling elsewhere. The second patient had a treatment-naive large MH with total retinal detachment. Both patients underwent vitrectomy with microscope-integrated optical coherence tomography-guided autologous neurosensory retinal autograft placement and silicone oil tamponade. At 6 months and 3 months follow-up, respectively, both patients had closed MHs, attached retinas, and improvement in visual acuity. CONCLUSION: Microscope-integrated optical coherence tomography provides intraoperative visualization of MHs and provides real-time feedback regarding dimensions of the retinal autograft, thus aiding in accurate sizing of the graft. This ensures that the autograft fits snugly in the MH, thereby restoring macular structure and improving visual acuity.

Posterior Segment Optical Coherence Tomography in Uncooperative Paediatric Patients Using Exo-Illumination and Microscope-Integrated Optical Coherence Tomography.

BACKGROUND AND OBJECTIVE: To describe a non-invasive technique for the acquisition of retinal optical coherence tomography (OCT) scans in paediatric patients undergoing examination under general anaesthesia (EUA) using microscope-integrated OCT (MIOCT). STUDY DESIGN: Prospective observational study Methods and Material: The study included 10 paediatric patients undergoing EUA for posterior segment pathology. These patients underwent OCT using MIOCT. No sclerotomy was made during imaging. The fundus was externally illuminated with a 25 gauge endoilluminator probe placed at the limbus and directed towards the posterior pole to aid in image acquisition by MIOCT (exo-illumination). Imaging for all patients was done by two trained vitreoretinal surgeons independently. Acquisition time was recorded for each surgeon. Interobserver variability in acquisition time and image quality was assessed to estimate the reliability of the novel imaging technique. RESULTS: In nine cases (90%), MIOCT successfully imaged the posterior segment pathology while in one case (10%) of X-linked retinoschisis, it failed to detect an inner retinal break located anteriorly at the equator. The mean acquisition time for surgeons one and two was 211.75 ± 26.00 and 212.58 ± 23.47 seconds, respectively. There was no significant difference in total image acquisition time between the two surgeons (P = 1.0) and the findings of both surgeons were comparable for structural morphology. 4x4 mm-sized scans provided the best delineation in macular pathology, while a 16x16 mm scan size was best suited for localising the area of interest and post-equatorial pathology. CONCLUSION: Using this technique acquisition of posterior segment OCT scans can be achieved non-invasively, using exo-illumination and MIOCT in paediatric patients undergoing EUA.