Epidemiology, clinical profile, management, and outcome of COVID-19-associated rhino-orbital-cerebral mucormycosis in 2826 patients in India - Collaborative OPAI-IJO Study on Mucormycosis in COVID-19 (COSMIC), Report 1.

Purpose: COVID-19-associated rhino-orbital-cerebral mucormycosis (ROCM) has reached epidemic proportion during India's second wave of COVID-19 pandemic, with several risk factors being implicated in its pathogenesis. This study aimed to determine the patient demographics, risk factors including comorbidities, and medications used to treat COVID-19, presenting symptoms and signs, and the outcome of management. Methods: This was a retrospective, observational study of patients with COVID-19-associated ROCM managed or co-managed by ophthalmologists in India from January 1, 2020 to May 26, 2021. Results: Of the 2826 patients, the states of Gujarat (22%) and Maharashtra (21%) reported the highest number of ROCM. The mean age of patients was 51.9 years with a male preponderance (71%). While 57% of the patients needed oxygen support for COVID-19 infection, 87% of the patients were treated with corticosteroids, (21% for > 10 days). Diabetes mellitus (DM) was present in 78% of all patients. Most of the cases showed onset of symptoms of ROCM between day 10 and day 15 from the diagnosis of COVID-19, 56% developed within 14 days after COVID-19 diagnosis, while 44% had delayed onset beyond 14 days. Orbit was involved in 72% of patients, with stage 3c forming the bulk (27%). Overall treatment included intravenous amphotericin B in 73%, functional endoscopic sinus surgery (FESS)/paranasal sinus (PNS) debridement in 56%, orbital exenteration in 15%, and both FESS/PNS debridement and orbital exenteration in 17%. Intraorbital injection of amphotericin B was administered in 22%. At final follow-up, mortality was 14%. Disease stage >3b had poorer prognosis. Paranasal sinus debridement and orbital exenteration reduced the mortality rate from 52% to 39% in patients with stage 4 disease with intracranial extension (p < 0.05). Conclusion: : Corticosteroids and DM are the most important predisposing factors in the development of COVID-19-associated ROCM. COVID-19 patients must be followed up beyond recovery. Awareness of red flag symptoms and signs, high index of clinical suspicion, prompt diagnosis, and early initiation of treatment with amphotericin B, aggressive surgical debridement of the PNS, and orbital exenteration, where indicated, are essential for successful outcome.

Sensitivity and specificity of automated analysis of single-field non-mydriatic fundus photographs by Bosch DR Algorithm-Comparison with mydriatic fundus photography (ETDRS) for screening in undiagnosed diabetic retinopathy.

Diabetic retinopathy (DR) is a leading cause of blindness among working-age adults. Early diagnosis through effective screening programs is likely to improve vision outcomes. The ETDRS seven-standard-field 35-mm stereoscopic color retinal imaging (ETDRS) of the dilated eye is elaborate and requires mydriasis, and is unsuitable for screening. We evaluated an image analysis application for the automated diagnosis of DR from non-mydriatic single-field images. Patients suffering from diabetes for at least 5 years were included if they were 18 years or older. Patients already diagnosed with DR were excluded. Physiologic mydriasis was achieved by placing the subjects in a dark room. Images were captured using a Bosch Mobile Eye Care fundus camera. The images were analyzed by the Retinal Imaging Bosch DR Algorithm for the diagnosis of DR. All subjects also subsequently underwent pharmacological mydriasis and ETDRS imaging. Non-mydriatic and mydriatic images were read by ophthalmologists. The ETDRS readings were used as the gold standard for calculating the sensitivity and specificity for the software. 564 consecutive subjects (1128 eyes) were recruited from six centers in India. Each subject was evaluated at a single outpatient visit. Forty-four of 1128 images (3.9%) could not be read by the algorithm, and were categorized as inconclusive. In four subjects, neither eye provided an acceptable image: these four subjects were excluded from the analysis. This left 560 subjects for analysis (1084 eyes). The algorithm correctly diagnosed 531 of 560 cases. The sensitivity, specificity, and positive and negative predictive values were 91%, 97%, 94%, and 95% respectively. The Bosch DR Algorithm shows favorable sensitivity and specificity in diagnosing DR from non-mydriatic images, and can greatly simplify screening for DR. This also has major implications for telemedicine in the use of screening for retinopathy in patients with diabetes mellitus.

Posterior Chamber Scleral Fixation of Intraocular Lenses in Post-Vitrectomised Aphakic Eyes.

INTRODUCTION: The best method of aphakia correction is in the bag implantation of Posterior Chamber Intraocular Lens (PCIOL). When this ideal procedure is not possible due to lack of integrity of posterior capsule or zonules, the other alternatives are broadly categorized into two: extraocular and intraocular. Whereas, the former includes contact lenses and aphakic glasses, the latter ones are further divided into anterior and posterior chamber methods. Anterior Chamber Intraocular Lenses (ACIOL) can be with or without iris claw. At the posterior chamber, fixation of the lenses can be with glue or sutures. When there is combined Pars Plana Vitrectomy (PPV) and lensectomy or if the indication of PPV is dropped nucleus or intraocular lens, a modality of aphakia correction should be devised. Posterior Chamber Scleral Fixation of Intraocular Lenses (PCSFIOL) with sutures is a preferred method because of its low complication profile. However, data on correction of aphakia after combined PPV and lensectomy is limited. To fill in this gap in knowledge, we evaluated the secondary PCSFIOL in aphakic eyes after previous PPV and lensectomy. AIM: To assess the outcome and complication profile of a large series of patients who underwent secondary PCSFIOL implantation with sutures after combined PPV and lensectomy. MATERIALS AND METHODS: Records of all patients who had undergone secondary PCSFIOL implantation with sutures after combined PPV and lensectomy from 2010 to 2014 were reviewed retrospectively for visual outcomes and complications. Patients' demographic data, indication for PPV, best corrected preoperative and postoperative visual acuities, complications of surgery, and indications of PCSFIOL and length of follow up were collected and analyzed. RESULTS: A total of 148 eyes of 148 patients (127 males and 21 females) were identified. Mean age at surgery was 32.5±8 years (range 2.5-73 years) with a mean follow up 23±14 months (range 3-114 months). A total of 95.27%, 2.70% and 2.02% of patients had improvement, maintenance and worsening of their final postoperative visual acuities respectively. A total of 32 (21.62%) of 148 eyes had postoperative complications from PCSFIOL with Epiretinal Membrane (ERM) formation being the most common. They all required one form of management or the other. Suture breakage leading to PCSFIOL subluxation or dislocation occurred in four eyes (2.70%). CONCLUSION: PCSFIOL with sutures is a preferred method in the management of post-vitrectomised aphakic eyes when the capsular or zonular support is not adequate for in the bag implantation of posterior chamber intraocular lenses.

Endocapsular hematoma: a rare form of ocular hemorrhage after thrombolysis with streptokinase.

CONTEXT: Endocapsular hematoma has previously been described as a cataract surgery complication more commonly observed in eyes receiving a combined cataract and glaucoma surgery. However, it can also be a rare form of ocular bleed following thrombolysis with streptokinase. CASE REPORT: A 65-year-old diabetic male presented to us with complain of sudden painless diminution of vision in his left eye, which he developed while he was being thrombolysed with streptokinase administered intravenously for an episode of acute myocardial infarct. On examination, left eye was pseudophakic with collection of blood in the capsular bag (Endocapsular hematoma). CONCLUSION: Endocapsular hematoma can be a rare form of ocular bleeding complicated by thrombolysis. Reporting this case becomes more relevant in the present era with increasing number of patients suffering from ischemic heart disease and likely to undergo thrombolysis.