Nodular scleritis-a rare presentation of COVID-19& variation with testing

Purpose

– To report a rare case of patient presenting with nodular scleritis and SARS-CoV2.

Observations

This case highlights a unique presentation of SARS-CoV2 positive patient with nodular scleritis as a presenting feature. Patient initially had ocular symptoms and developed only mild systemic features subsequently which did not require hospitalization. COVID testing done at different time points showed variable results which correlated with the ocular features. This patient was followed up during quarantine using tele-ophthalmology.

Conclusion and importance

This case highlights a possible rare presentation of a SARS-CoV2 patient with nodular scleritis and also importance of tele medicine during these unprecedented times.

"Bilateral Sequential Acute Macular Neuroretinopathy in an Asian Indian Female with β Thalassemia Trait following (Corona Virus Disease) COVID-19 Vaccination and Probable Recent COVID Infection- Multimodal Imaging Study."

INTRODUCTION

Corona virus disease (COVID-19) has been associated with a variety of ophthalmic manifestations including acute macular neuroretinopathy and paracentral middle maculopathy. Posterior segment manifestations after post COVID-19 vaccinations have been reported.

CASE REPORT

A 25- year-old Asian Indian female developed sequential bilateral AMN following a single dose of COVISHIELD™ vaccine. On investigations she was found to have a β thalassemia trait. Presentation started unilaterally and progressed to the other eye after a month. On clinical examination, the fundus was apparently normal in both eyes. Significant changes suggestive of AMN were seen on multimodal imaging of the posterior segment of the respective eye at the time of involvement which resolved spontaneously in due course.

CONCLUSION

We report a temporal association of COVID-19 vaccination and AMN.

Trends in teleconsultations for uveitis during the COVID-19 lockdown

Purpose:

To study the use of teleophthalmology as a tool to manage patients with uveitis and to describe the experience of teleconsultation for uveitis at a tertiary eye care hospital in India during the two waves of the COVID-19 pandemic.

Methods:

A prospective observational case series of uveitis patients seeking teleconsultations during the first (March 25–May 2020) and second lockdown (April 27 to June 21, 2021) in a tertiary eye care center were analyzed.

Results:

There were 79 teleconsultations in the first and 89 teleconsultations in the second lockdown. A majority of the patients presented in the age group of 41–60 years in both the lockdowns. There were both new or primary consultations and follow-up patients (6% vs. 94%) in the first lockdown, and similarly in the second lockdown (8% new vs. 92% follow-up). The majority of patients resided in Bengaluru city (78% in the first and 76% in the second lockdown). After evaluation through video consultation, only 15% required a hospital referral in the first lockdown, whereas in the second lockdown, 21.3% were referred to the hospital. During the second lockdown, 20% presented with COVID-19 infection-related ailments.

Conclusion:

Based on our preliminary experience using a customized smartphone-based application for teleconsultation, we found it to be an alternative option to provide continuation of ophthalmic care to uveitis patients. Given the current COVID-19 situation, it can help avoid physical visits of uveitis patients to the hospital.

Posterior segment manifestations and imaging features post-COVID-19

Background

To report the posterior segment (uvea and retinal) manifestations and imaging characteristics of eyes of patients with and after coronavirus disease 2019 (COVID-19).

Methods

We searched the PubMed/MEDLINE database to identify relevant articles using the following search terms: COVID-19, SARS-CoV-2, retina, uvea, optic nerve, retinal findings, posterior segment manifestations, and endophthalmitis. Articles published from December 1, 2019, to May 30, 2021, and indexed in PubMed/ MEDLINE were screened.

Results

For the purpose of this review, we included clinical features of 26 case reports and 8 case series. The posterior segment manifestations reported included cotton wool spots, retinal hemorrhages, central serous retinopathy, papillophlebitis, optic neuritis, panuveitis, multifocal retinitis, necrotizing retinitis, central retinal artery/vein occlusion, and Purtschner like retinopathy. In this review, we have also included optical coherence tomography angiography (OCTA) features that have been described in COVID-19 patients with pneumonia.

Conclusions

COVID-19 patients can experience uveo-retinal manifestations even after recovery. These patients, even if asymptomatic for eye symptoms, should undergo an eye evaluation to rule out posterior segment involvement. OCTA performed in these patients revealed microvascular changes in the superficial and deep retinal plexuses. Some of these patients may require anticoagulant or antiplatelet therapy.

Optical coherence tomography angiography (OCTA) of retinal vasculature in patients with post fever retinitis: a qualitative and quantitative analysis

Post fever retinitis is a heterogenous entity that is seen 2-4 weeks after a systemic febrile illness in an immunocompetent individual. It may occur following bacterial, viruses, or protozoal infection. Optical coherence angiography (OCTA) is a newer non-invasive modality that is an alternative to fundus fluorescein angiography to image the retinal microvasculature. We hereby describe the vascular changes during the acute phase of post fever retinitis on OCTA. Imaging on OCTA was done for all patients with post fever retinitis at presentation with 3 × 3 mm and 8 × 8 mm scans centred on the macula and corresponding enface optical coherence tomography (OCT) scans obtained. A qualitative and quantitative analysis was done for all images. 46 eyes of 33 patients were included in the study. Salient features noted were changes in the superficial (SCP) and deep capillary plexus (DCP) with capillary rarefaction and irregularity of larger vessels in the SCP. The DCP had more capillary rarefaction when compared to the SCP. The foveal avascular zone (FAZ) was altered with an irregular perifoveal network. Our series of post fever retinitis describes the salient vascular features on OCTA. Although the presumed aetiology was different in all our patients, they developed similar changes on OCTA. While OCTA is not useful if there is gross macular oedema, the altered FAZ can be indicative of macular ischemia.

Topical interferon - A novel treatment for pseudophakic macular edema

Purpose:

The aim of this study was to evaluate the efficacy of topical interferon (IFN) therapy in pseudophakic cystoid macular edema (P-CME).

Methods:

This is a prospective, interventional case series of patients with P-CME. Patients presenting with P-CME were given the option of topical IFN therapy against conventional treatment with oral, topical, intravitreal, and periocular steroid therapy and antivascular growth factors. Patients who consented for the same were advised to use the IFN drops four times/day. Commercially available injection IFN alfa-2b was reconstituted to prepare the eye drops (1 MIU/ml). Optical coherence tomography (OCT) was done at the baseline and on each review visit until complete resolution of P-CME.

Results:

Eight eyes of eight patients diagnosed with P-CME were studied. Mean central macular thickness (CMT) on OCT at the presentation (n = 8) and at 4 weeks post topical IFN therapy (n = 6) was 560.1 μm (range: 349–702 μm) and 344.33 μm (range: 250–390 μm), respectively. All eyes except one had posterior capsular rent (PCR). Five patients had regular follow-up until resolution. The mean duration of complete first resolution of P-CME was 5 weeks (range: 4–7.1 weeks) in those patients. Relapse was seen in three patients who responded after resuming or continuing the therapy. Case 1 had 9 months follow-up after completion of IFN therapy, and no recurrence was noted. No ocular or systemic side effects related to the topical IFN therapy were noted clinically, except papillary conjunctivitis in one patient.

Conclusion:

Topical IFN therapy can be a noninvasive, economical, and effective choice of treatment for P-CME, especially in the case of PCR, and where steroids are contraindicated.

Choroidal Thickness in Multifocal Dendritic and Placoid Serpiginous-Like Choroiditis: A Comparative Study

BACKGROUND AND OBJECTIVE

To study spectral-domain optical coherence tomography (SD-OCT) characteristics in multifocal advanced dendritic serpiginous-like choroiditis (D-SLC) and placoid serpiginous-like choroiditis (P-SLC).

PATIENTS AND METHODS

Retrospective, comparative study. SD-OCT features were studied in both the groups. Area of involvement (AoI) due to SLC lesions was calculated, and cases with comparable AoI from both the groups were subclassified into Group A (subgroup D-SLC) and Group B (subgroup P-SLC). Central choroidal thickness (CT) was measured, and comparative analysis was performed.

RESULTS

Thirty-four eyes (15 D-SLC, 19 P-SLC) of 28 patients were studied. Mean AoI for Group A (n = 10) and for Group B (n = 12) was 197,066.50 units (range: 139,602 to 267,151 units) and 203,407.33 units (range: 148,156 to 285,048 units), respectively (P = .553). Mean central CT was 217.92 µm for DSLC and 152 µm for P-SLC (P = .01).

CONCLUSIONS

The choroid was significantly thinner at the resolution in P-SLC than in D-SLC form. P-SLC renders more choroidal destruction and may warrant aggressive treatment. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:438-442.].

Role of multicolour imaging in post-fever retinitis involving posterior pole

PURPOSE

To describe composite multicolour (MC) imaging features along with the monocoloured fundus reflectance images in active and resolving stages of post-fever retinitis (PFR).

METHODS

Retrospective image analysis of cases of PFR who underwent dilated retinal clinical examination followed by optical coherence tomography and MC imaging.

RESULTS

Twenty-five eyes of 18 patients diagnosed with PFR were included. There were 11 males and 7 females. Mean age of patients was 30.63 years. The retinitis lesion appeared bright white on MC image and white mainly on blue and green reflectance images during the active stages of PFR. The lesion appeared dull-grey to greyish white during the resolving stages and as dull-green in resolved cases. The active stages showed the presence of intraretinal/subretinal fluid which appeared as green colour on MC images and less green to normal during resolving stages. Hard exudates were seen as bright yellow- or orange-coloured spots on MC image during the resolving stages of the disease.

CONCLUSION

The different stages of PFR show different colour on multicolour image and different reflectance patterns on individual colour reflectance channels. Hence, multimodal fundus imaging with different wavelength can be helpful for differentiation of activity in PFR.

Global Ophthalmology Practice Patterns during COVID-19 Pandemic and Lockdown

Aim: To assess the impact of practice patterns amongst global ophthalmologists during severe acute respiratory syndrome Coronavirus 2 (SARS Cov2) causing Corona virus disease (COVID-19) and understand the various modifications made to address emergency surgeries and practice needs.Methods: An online survey was sent to practicing ophthalmologists around the world through email, Whatsapp™ ListServ17.0™ (for pediatric ophthalmologists), WeChat™ (China) and ophthalmology associations (Indonesia, Philippines, Ireland). All queries were collected and categorized. Responses to the queries were given according to the recommendations by the Ophthalmology association. Practices ability to deal with the COVID were also classified according to country and type of access to PPE. Statistical analyses of the association between these data and queries, where appropriate were carried out.Results: One thousand nine hundred sixteen ophthalmologists were invited to participate in a survey between April 10^th and April 30^th, 2020 of which 1207 responded, which is a response rate of approximately 63%. The majority of respondents were from India, Indonesia, China, Singapore and the USA. Our study indicates a precipitous drop in surgical procedures with 46% (n = 538) ophthalmologists ceased to operate on their patients and almost 40% (n = 486) were doing less than 25% of their original number of surgeries. The intent to resume elective surgeries was a consideration in 41% (n = 495) after an evaluation of the situation and in consultation with professional bodies. More than 2/3 of the respondents (n = 703) made it a priority to use and mandate their patients to practice physical distancing, wearing masks, and hand dis-infection for protection to limit the spread of infection.Conclusion: This global survey provides a real-world assessment of diverse practices that were in various forms of "shut down mode" and circumstances with varying capabilities to deal with COVID. It is unprecedented that the collective wisdom for a curtailment of practice has had an enormous immediate and far reaching implications on the livelihoods of ophthalmologists, their staff, and their families. Nevertheless, ophthalmologists and their staff remain resilient and have adapted to these changes pragmatically.

Topical interferon in recurrent inflammatory macular edema following a cat bite

INTRODUCTION

Treating chronic macular edema (CME) post endophthalmitis is a challenge. Use of steroids may reactivate the infection and repeated intravitreal therapy with anti-vascular growth factor inhibitors (Anti-VEGF) puts the patient again at the risk of exacerbation of inflammation or endophthalmitis. We describe a case of CME post traumatic endophthalmitis successfully treated with topical interferon therapy.

CASE DESCRIPTION

A 34-year-old Asian Indian lady with a history of cat bite to her right eye and treated elsewhere as traumatic endophthalmitis with recurrent macular edema, presented to us 1 year after the injury. She had received anti-VEGF injection for same. Her medical history was non-contributory except for close contact with her cat. Therapeutic trials with oral doxycycline followed by oral albendazole with steroids, as well as repeated anti-VEGF therapy failed to prevent recurrence of CME. Patient's steroid responsiveness and reluctance for injections, made us to opt for a novel topical Interferon therapy. Macular edema resolved in 2 months. Interruption of interferon therapy due to COVID-lock down resulted in recurrence of the CME, which again responded well to interferon monotherapy.

CONCLUSION

Topical interferon may have a role in the treatment of inflammatory macular edema and can serve as a, safer, economical and non-invasive treatment option compared to intravitreal steroids and anti-VEGFs.

"Post Coronavirus Disease (COVID-19) Reactivation of a Quiescent Unilateral Anterior Uveitis"

Coronavirus disease (COVID-19) can be associated with ophthalmic manifestations like conjunctivitis, retinal haemorrhages, retinal vascular occlusions, papillophlebitis, and Adie’s syndrome. We herein report for a case of a unilateral acute anterior uveitis which was quiescent for 13 years and was reactivated post COVID-19 infection in a 43-year-old Asian Indian male. He had a past history of recurrent unilateral granulomatous anterior and intermediate uveitis in the right eye (RE), and all the investigations done 14 years ago were negative and had been on treatment with topical and oral steroids. He developed cataract 6 months later in the RE and underwent surgery. Patient was in remission for the past 13 years. Uveitis investigations for the present episode were all negative. Topical steroid and cycloplegic helped in resolution of the uveitis. This may be the first instance of reactivation of a quiescent unilateral anterior uveitis following COVID-19 infection.

Epidemic retinitis and community outbreaks

Purpose:

The objective of this study was to correlate seasonal variation of epidemic retinitis (ER) with concurrent community outbreaks.

Methods:

This is a retrospective, observational, comparative study conducted in a tertiary care eye hospital in south India. Monthly variation in number of ER cases in comparison with reported community outbreaks by Integrated Disease Surveillance Program (IDSP) from 2009 to 2020 in the same region were studied. Month-wise graphs against number of patients were plotted for ER and for each community outbreak.

Results:

ER was diagnosed in 163 patients. Diagnosis of presumed rickettsial ER was made in 48 cases (29.44%), chikungunya in 5, dengue in 3 and typhoid in 6 cases, while in other cases the etiological diagnosis remained uncertain (n = 101). Multiple positive serological tests were seen in 6 patients (Weil Felix Test (WFT) with WIDAL in 4 and chikungunya IgM with WFT in 2 patients). Relevant reported outbreaks by IDSP were: Pyrexia of unknown origin (PUO) (n = 5148), Chikungunya (n = 6577), Dengue (n = 7350), Measles (n = 1422), Mumps (n = 881), Rubella (n = 288), Malaria (n = 2262), Chicken Pox (n = 2385), Typhoid (n = 597), Kyasanur Forest Disease (n = 381), Scrub Typhus (n = 13), Typhus fever (n = 4), Japanese Encephalitis (n = 15). None of the outbreak graphs pattern was identical or similar to the graph of ER. Inverse relation of the graph of dengue outbreak with ER was observed.

Conclusion:

Inverse correlation between dengue and ER should be further studied for causation, which we believe may prove dengue as least common cause. Reporting of rickettsial outbreaks should be enhanced by undertaking statewide awareness and procurement of gold standard tests.

"Old wine in a new bottle" - post COVID-19 infection, central serous chorioretinopathy and the steroids

INTRODUCTION

Corona virus disease (COVID-19) pandemic can cause myriad of ocular manifestations. We report a case of unilateral multi focal central serous retinopathy, post COVID-19 infection in an Asian Indian female.

CASE PRESENTATION

A 42-year-old female presented to us with unilateral blurring, in the right eye (OD), 12 days after COVID-19 infection. She had fever, chills, shortness of breath and cough with tiredness and was COVID- RT PCR positive. She was administered intravenous and oral antibiotics with injection heparin/remdesivir, during her 7 day stay at the hospital. She was also on steroid inhalers. She had no systemic history of note. On ocular evaluation, her corrected distance visual acuity was 20/40 in OD and 20/20 in left eye (OS). Anterior segment was normal. Anterior vitreous was clear. Fundus examination of the OD showed central serous retinopathy (CSCR) with OS being normal.

CONCLUSION

CSCR can occur post COVID-19 due to steroid administration and physicians administering it should be aware of this and refer the patients to an ophthalmologist earlier.

Post COVID-19 Ophthalmic Manifestations in an Asian Indian Male

Introduction: The Ocular manifestations of coronavirus disease 2019 (COVID-19) reported include conjunctivitis, conjunctival hyperemia, chemosis, epiphora, episcleritis, retinal manifestations included cotton wool spots (CWS), micro-hemorrhages, papillophlebitis and neuro-ophthalmic manifestations.Purpose: To report post COVID-19 ophthalmic manifestations using multimodal imaging.Results: A 66-year-old Asian Indian male presented to us with bilateral blurring of vision, RE>LE, of 3 days following a diagnosis of COVID-19 disease. Corrected distance visual acuity were 20/2666 and 20/25 in the right (RE) and left (LE) eyes respectively. He had bilateral anterior chamber inflammation with a relative afferent pupillary defect in the RE. RE showed central retinal artery occlusion(CRAO) with CWS, few flame-shaped retinal hemorrhages and disc edema and hyperemia. LE had disc edema and hyperemia, few flame-shaped retinal hemorrhages, cystoid changes and CWS. A diagnosis of bilateral panuveitis and papillitis with CRAO in the RE was made.Conclusion: Our patient developed a vascular occlusion with panuveitis, which possibly represents an immune mediated event following COVID-19. Patients should be warned about possible ophthalmic sequelae even after recovery.