Niranjan Karthik Senthil Kumar

Mucormycosis is an uncommon, opportunistic fungal infection. The most crucial decision in the management of rhino-orbital mucormycosis is when to advise exenteration. This study aims at understanding the pattern of cases which progressed and had extensive involvement of the entire orbital cavity with mild intra cranial extension requiring exenteration as life salvage measure in the setting of epidemic of mucormycosis in a pandemic of COVID – 19. Patients suspected or diagnosed with invasive orbital mucormycosis visiting our hospital were admitted and included in the study. CT PNS with orbit were done for all patients and MRI brain with orbit were done in patients in whom intracranial spread and involvement of optic nerve were present. Patients were started on liposomal intravenous amphotericin B (5mg/kg/day) and intraorbital amphotericin B injection when indicated and closely monitored for clinical progression. All patients were taken up for FESS and if positive for mucormycosis on histopathological examination. In cases wherever exenteration was indicated, after confirming that there was no perception of light and obtaining informed consent with psychiatric counselling patient was taken up for orbital exenteration. Lid sparing exenteration was the method of choice. A total of 41 patients out of 696(5.89%) underwent exenteration out of which 21(51.2%) were right sided and 20(48.8%) were left sided. 12 patients (29.2%) of those who had undergone exenteration did not have a history of being tested positive/ been symptomatic for COVID 19. 1 patient (2.4%) was not diabetic. All patients (100%) had sinonasal involvement (Involvement of one or more paranasal sinuses) with involvement of orbital cavity to different degrees. 4 out of 41(9.75%) patients had deteriorated and required ICU care. 1 patient succumbed to death (2.4%) due to multiple comorbidities. On histopathological examination of exenteration specimen, 2(4.87%) patients turned out to be negative for mucormycosis. In 32(78.04%) of them the socket healed well while 5(12.1%) had slough who required 2 or more sittings of sloughectomy. As mucor is angio invasive rapidly progressive highly fatal infection close monitoring for invasion into structures like apex of orbit and intra cranial spread is essential for timely intervention and decision to perform exenteration. This is crucial for arrest of progress and life salvage.   Keywords: Mucormycosis, Exenteration, ROCM, COVID­19

Orbital apex syndrome (OAS) is an uncommon clinical presentation consisting of complete ophthalmoplegia with vision loss, involving cranial nerves II, III, IV, V, and VI. OAS may result from trauma, malignancy, infection, inflammation, or vascular origins. Aims of the study were to analyse the incidence and presentation of orbital apex syndrome in rhino-orbital mucormycosis in a tertiary care hospital. A total of 29 cases (4.1%) out of 696 cases of invasive ROCM with OAS as a presenting feature were documented. Amphotericin B in both retrobulbar and intravenous routes played a crucial role in arresting the spread of the disease allowing only 8 (27%) cases to show disease progression. FESS if done appropriately with efficient debridement of necrotic infective tissue can be a powerful tool in redirecting the course of disease for the better (only 2 of 8 patients with CST at the time of presentation had a history of FESS done prior. ROCM is a severe, emergent and fatal infection requiring multidisciplinary management. It may often present with OAS initially. Mucormycosis must be considered in such patients and timely aggressive management must be initiated to avoid disastrous morbidity and mortality.   Keywords: Orbital apex syndrome, Rhino-orbito-cerebral mucormycosis

Aim: To analyze clinico-epidemiological trends in Retinitis Pigmentosa (RP) cases and syndromes associated with RP. Materials and Methods: This is a prospective observational case series. All cases found to have clinical features suggestive of RP were studies. The period of study was for twelve months. Detailed history taking, General and ocular examinations were performed meticulously to look for various associations and findings related to RP. Results: Among 55 patients of Primary RP, 38 (69%) were males and 17 (31%) females. 69.9% had the onset in 1 decade, 14.5% in 2 decade and 16.36% beyond 2 decade. In 1 decade of life, pattern of inheritance showed a predominance of autosomal recessive pattern (34.5%) followed by sporadic (27.2%). 30 out of 55 cases (54%) had positive family history of night blindness while remaining 25(46%) were sporadic in nature. 40 (72.7%) had typical RP, 4 cases had atypical RP (7.2%) and 11 (20%) syndromic RP. Of 11 cases which had syndromic associations, most common was Usher syndrome being 5 (45%). Regarding treatment, myopia was corrected with best glasses in 25 cases and 5 required low vision aids. 35 cases (64%) maintained visual acuity and fields. Conclusion: Retinitis pigmentosa presents in an isolated or syndromic manner (20%). Periodic testing helps in timely detection of progression of disease. Correction of refractive error and use of low vision aids allows patients to pursue many activities of daily living better. Supportive genetic counselling and utility of ERG in detecting early loss of photoreceptor function.   Keywords: Syndromic associations, Bardet biedl syndrome.

Purpose:  To evaluate and analyze the causes of visual impairment, handicap, and blindness in a tertiary eye hospital among patients applying blindness certificates in Chennai.   Materials and Methods:  Applications for blindness certificates were analyzed over two years (2019-2021). The main cause of blindness, visual handicap, and visual impairment in these applications was ascertained by age group and etiology. Visual impairment disability percentages and definitions proposed by the Government of India [category 0-4, 20-100%] were used to categorize and give a percentage to all applicants. Results were compared with data from studies on blindness certificates and population-based studies.   Results:  A total of 118 applications were reviewed. The mean age was 23.5±7.9 (range 12 to 65 years). The most common causes of blindness were retinitis pigmentosa and optic atrophy. In the age group 0-15 years, phthisis bulbi followed by microphthalmos were found to be the most common cause of blindness. Among the 15-30 years age group, macular pathology was the most common cause of visual blindness. Between 30-40 years of age group Retinitis pigmentosa is most common. Above 40-60 years of age, optic atrophy and glaucoma were the most common cause of blindness.  Conclusion:  Data from applications for blindness certificates provide valuable information regarding different causes of visual blindness provide an insight into the overall trends in disease profile and service delivery.    Keywords: Blindness certificate, Causes of blindness, Economic blindness, Visual impairment.

Aim: To study the incidence of eyelid tumours pertaining to age, sex, lid, globe or orbital involvement and analyse the various aspects of treatment modalities and their functional and cosmetic outcome.  Materials and Methods: A prospective study of 40 cases of eyelid tumours over a period of 1 year, both benign and malignant eyelid lesions were included and those with inflammatory lesions were excluded. Patients were evaluated and treated with appropriate modalities and the outcome was analysed. Results: Malignant tumours were common in the age group between 60-85 years and benign tumours were common in the age group of 30-45 years. Benign tumours were more common among males and malignant tumours more common among females. Out of the 40 cases, 28 (70 %) eyelid lesions were benign and 12 (30%) cases were malignant. Benign tumours were found more commonly in the upper lid and malignant tumours in lower lid. Squamous papilloma was found to be the most common benign tumour, followed by pyogenic granuloma. Meibomian carcinomais the most common malignant tumour. Most common presentation of malignant eyelid tumour was ulcerative growth pattern. Meibomian carcinoma presented in the form of nodule and ulcerative growth pattern. The treatment for most of the benign tumour was simple excision and malignant tumour was wide local excision with 4-5 mm margin clearance. Glabellar rotation flap was performed in one case of meibomian carcinoma involving the medial aspect of lower lid after excision. Hughes tarso-conjunctival flap was performed in two cases of squamous cell carcinoma and basal cell carcinoma, after tumour excision as the defect involved more than 75% of the lower lid without involvement of canthus. Two cases one each of sebaceous carcinoma and squamous cell carcinoma involving the lateral aspect of lower lid was reconstructed after excision, with Tenzel flap. In one case of sebaceous gland carcinoma with diffuse involvement of the upper lid the was excised and reconstructed with Cutler-Beard technique. Conclusion: Histopathologic examination of all excised lesion must be done as an innocuous looking lesion might be malignant. Early clinical suspicion of malignancy and confirmation by incisional biopsy will aid in planning wide excision and appropriate method of lid reconstruction depending on the amount of lid loss. After wide excision of malignant tumour appropriate lid reconstruction technique is done as a primary procedure in all our patients and we could obtain good outcomes with no recurrences. Advanced tumours with orbital involvement and recurrent tumour need adjuvant chemotherapy or radiotherapy.   Keywords: Lid tumours, Squamous Papilloma, Sebaceous gland carcinoma, Tenzel Flap, Cutler­Beard technique

Aim: To study the incidence of cerebral visual impairment among children with history of perinatal neurological insult and congenital brain anomalies and to analyze the outcome following visual intervention programme.  Materials and Methods: A prospective interventional study, examining 100 children less than 7 years over a period of 1 year. All children with history of perinatal hypoxia, neonatal hypoglycemia, neonatal seizures, infantile spasm, epilepsy, congenital hydrocephalus, congenital brain anomalies, CNS infections, traumatic brain injury and post cardiac surgery, excluding children with ocular visual impairment.  Results: Of the 100 children studied, the incidence of CVI was 87%. The associated ocular problems were found to be low visual acuity seen in 85%, strabismus in 25%, refractive error in 39%, Nystagmus in 21% and oculomotor apraxia in 6%. The most common etiology was hypoxic ischemic encephalopathy, contributing to 30% of the cases and most common MRI findings were periventricular leukomalacia, seen in 42%. CVI Range was used for functional visual assessment. Visual intervention rather than visual stimulation was taught to the primary care giver and children were followed up every 3 months. 26% of children had improved in their functional vision after 6 months of Individualized intervention.  Conclusion: Early identification and individualized visual intervention, integrating them into many activities of the child across the whole day, form a crucial part of the visual outcome. Improvement in vision creates access to a world of cognitive and motor development.    Keywords: Cerebral visual impairment, Cardiac arrest