Diminution Of Vision Research Articles

Management of rhino-orbito-cerebral mucormycosis: a clinico-radiological study—an institutional experience

BackgroundMucormycosis in the setting of COVID-19 has given rise to the concept of “epidemic within a pandemic.” Once known to be a rare fungal disease, mucormycosis has now been regrouped under emerging pathogens. It has got special affinity for the immunocompromised, which is one of the main reasons for the flare up of the fungus during the second wave of COVID. The burden of the disease was felt globally, and India is facing the major brunt owing to our population and healthcare services ratio.ObjectiveIn our study, we have made an attempt to evaluate the clinical and radiological findings in patients of rhino-orbito-cerebral mucormycosis (ROCM) and to formulate a management protocol which will benefit such patients in forthcoming years.MethodsThis is a retrospective single-center study in Northern India. A total of 350 patients, affected by ROCM, were included in the study. Medical records of these patients were reviewed. Their clinical manifestations, nasal endoscopic findings, microbiological and radiological records, extent of disease, treatment profile, surgical interventions, and outcomes were analyzed. Nasal swab which was sent for KOH mount/fungal culture revealed broad aseptate filamentous fungi branching at right angles. All patients received intravenous amphotericin B and had undergone extensive surgical debridement endoscopically. The maxillary sinus was the commonest paranasal sinus involved followed by the ethmoid sinuses. Tissue sent for histopathological examination confirmed mucormycosis, except for 3 cases.ResultsThe commonest presenting symptoms were cheek swelling with ophthalmoplegia, diminution of vision, and headache. The mean duration of follow-up was 8 months.The maxillary sinus was found to be involved in around 71% of the cases followed by the ethmoids and sphenoid. Thirty percent of the cases had visual complaints including diplopia and vision loss, whereas the palate was involved in around 35%. Nine patients had no perception of light in one eye on presentation, whereas 21 patients had perception of light only; 24 patients could count fingers close to face, and the rest had ambulatory vision. Three patients presented with facial palsy. All patients had favorable outcome except six who succumbed due to cerebral involvement and uncontrolled blood glucose levels.ConclusionA definite management protocol was formulated for ROCM which requires a multidisciplinary approach.

Isolated Unilateral Temporal Coloboma of the Lens

Lens coloboma is a rare congenital anomaly that occurs due to failure of the foetal fissure to close completely causing an incomplete formation of the lens, so usually inferonasal. Temporal lens coloboma is extremely rare; reported cases were associated with ocular or systemic anomalies. We report a rare case of unilateral atypical temporal lens coloboma without any iris abnormality and posterior segment coloboma or any other ocular or systemic anomaly.
 An 18-year-old female presented with a gradually progressive painless diminution of vision in her left eye for two years. There was no history of trauma, and family history was non-contributory. The systemic examination was normal. Ocular examination revealed a vision of 6/6 in the right eye and 6/60 in the left eye improving to 6/24 with pinhole and unilateral atypical temporal coloboma of the crystalline lens in the left eye after dilatation. The rest of the anterior segment and fundus examination was normal. No abnormality was detected in the right eye. The best corrected visual acuity of 6/6 OD and 6/9 OS was achieved with spectacle correction at 6 months of follow-up. This case is a rare presentation of unilateral atypical coloboma located temporally without any iris abnormality and posterior segment coloboma or any other ocular or systemic anomaly. Early correction of refractive error and astigmatism results in good prognosis.

A rare occurrence of superior retinochoroidal coloboma: A case report

Purpose: To brief a rare case of superior retinochoroidal coloboma and to analyze the possible embryogenic aspects involved in its provenance. Method: A case report. Result: This case report highlights an 11-year-old myopic girl who presented with diminution of vision in both eyes for the past 1 year. She had no other specific ocular complaints. The best corrected visual acuity was 6/18p and N24 in the left eye (OS) and 6/6 and N6 in the right eye (OD) at 30 cm. On detailed examination, all ocular structures were found to be normal except the fundus, which showed superior choroidal coloboma with foveal involvement in OS, with OD being normal. This is a rare phenomenon as most often, ocular coloboma is located in the inferior nasal quadrant with the involvement of the iris and/or crystalline lens. Conclusion: The rare finding in this case is the location of coloboma at the superior quadrant. Moreover, this coloboma case spares the iris and crystalline lens, making it even rarer in the category, considering the uncommonness of such cases.

The family of crooked arteries

Familial retinal arterial tortuosity syndrome (fRATs) is an autosomal dominant condition characterized by Tortuosity of second‐ and third‐order retinal arterioles but no retinal hemorrhages. We present a case series of a family of three affected members with fRATS. The 47-year-old father presented with diminution of vision, and we found preretinal and intraretinal hemorrhages in the macula. Retinal arterioles of the second‐ and third‐order were tortuous. We examined his children and found similar retinal findings. Clinical exome sequencing revealed a heterozygous c.1501G>A (p.Gly501Ser) mutation involving the COL4A1 gene. To our knowledge, this is the first case report of fRATS from India.

Cone dystrophy with supernormal rod response – A rare case report

Cone dystrophy with supernormal rod response (CDSRR), also known as potassium channel subfamily V, member 2 (KCNV2) retinopathy, is a rare autosomal recessive cone rod dystrophy, which derives its name from its characteristic full-field electroretinography (ERG) features and the causative gene mutation (KCNV2 gene). It is one of the rare eye retinal dystrophies where ERG is pathognomonic and directly carries the genetic imprint of the condition. Here, we discuss the case of a 9-year-old Indian child with history of diminution of vision in both eyes. Full-field ERG showed a characteristic response of supranormal scotopic b-wave amplitude at high luminance intensities along with broadened trough of the a-wave with late negative component with reduced and delayed photopic response suggestive of CDSRR.

Bilateral cataract in Fahr’s syndrome: A rare case presentation

Fahr’s syndrome refers to a rare syndrome characterized by symmetrical and bilateral intracranial calcification. A 17-year-old female presented with bilateral diminution of vision. The patient had a history of dystonia with distal limbs involvement. An ocular examination revealed a bilateral cataractous lens. CT scan of the brain and orbit revealed bilateral, large area of bilateral calcification over the thalamus, basal ganglia, subcortical white matter, dentate, and cerebellar hemisphere. The secondary causes of bilateral calcification were excluded to make the clinical diagnosis of idiopathic bilateral striopallidodentate calcinosis, which is known as Fahr’s syndrome. Our aim in this case is to highlight the ophthalmic manifestation of a rare neurological syndrome.

Multimodal imaging in fundus flavimaculatus with macular vitelliform lesion

We report a case of fundus flavimaculatus (FFM) with macular vitelliform lesion. The study was done in a center in eastern India. A 38-year-old male presented with painless diminution of vision. His best corrected visual acuity (BCVA) was 20/60 and 20/25 in the right and left eye, respectively. There were polymorphous, yellowish, mid-peripheral retinal flecks and foveal vitelliform lesions. Investigations were suggestive of FFM. We have described the various multimodal imaging modalities to differentiate FFM and vitelliform dystrophy. It is crucial to differentiate these diseases due to the difference in visual prognosis. We report a case of FFM with a foveal vitelliform lesion.

Retinal Toxicity from Ectoparasiticide Exposure or Coincidental?

Case Report: A 42 Year old male presented with complaints of sudden painless diminution of vision in RE for 3days, after fall of ectoparasticide (DELTAMETHRIN1.25%) in Right Eye. Uncorrected visual acuity in Right eye: counting fingers at 1/2metre, Left Eye: 6/6. Anterior segment evaluation showed Right and Left eye within normal limits. Pupils were 3mm round, regular, reactive to light in OU. Dilated Fundus Examination using indirect ophthalmoscopy showed Right Eye C:D:0.5, A:V 2:3 with subretinal fluid accumulation in macula and Left Eye normal fundus picture. A diagnosis of RE Central serous Chorioretinopathy (CSCR) was made using Optical Coherence Tomography. Discussion: With an incidence rate of 9.9 per 100,000, or roughly six times higher than that of women, CSCR mostly affects men. Acute or subacute central vision loss or distortion is the most prevalent symptom, and it typically affects men between the ages of 20 and 50.With regard to illnesses like CSCR, this case study aims to provide clinicians with more insight into the diagnosis, treatment, and management of pesticide-induced ocular damage. Conclusion: This is rare case of retinal toxicity following exposure to Deltamethrin.For an accurate diagnosis and management of CSCR, it is imperative to comprehend its risk factors, particularly the exposure to pesticides. Emphasizing eye protection and preventative health measures will help us safeguard our vision from environmental risks such as pesticide exposure.

A Case Report of Axenfeld-Rieger Anomaly

Axenfeld-Rieger (AR) syndrome is an inherited Autosomal Dominant (AD) disorder with ocular, dental, and craniofacial defects, whereas AR anomaly presents only with ocular changes. Hereby, the authors present a case report of 40-year-old male patient who reported to the Outpatient Department (OPD) with complaints of diminution of vision in Both Eyes (BE) for three years. There was a significant family history. Visual acuity was limited to hand movements in both eyes. Both eyes showed prominent Schwalbe’s line, iris atrophic patches, and ectropion uvea. Intraocular Pressure (IOP) was high in the Right Eye (RE) and within normal limits in the Left Eye (LE). No craniofacial or dental anomalies were detected. Gonioscopy revealed a closed angle with broad peripheral anterior synechiae in both eyes. Fundus examination revealed a Cup Disc Ratio (CDR) of 0.5 in the RE and 0.9 in the LE. AR anomaly is a rare case. Long-term follow-up of these cases is as important as early diagnosis and treatment to prevent blindness.

Case Report of Foveolitis with Optic Neuritis: A Barely encountered Ophthalmic Manifestation of Dengue

Dengue fever is a tropical disease which is endemic in tropical/subtropical nations like Nepal. Bilateral optic neuritis with unilateral foveolitis is an unusual dengue-related ophthalmic complication. We here present to you a case of bilateral optic neuritis with right eye foveolitis who initially presented with complaints of sudden diminution of vision in one eye following dengue fever. This report deals with prolonged treatment of rare ocular presentation of dengue infection. Patient had persistent myodesopsia and scotoma in the right eye even after 5 months of treatment with oral steroids. Dengue-related ophthalmic findings although rare, can have significant and long-lasting visual impairment if not treated timely and appropriately.

Eyeing risks: Navigating ophthalmic challenges in sinus surgery

This is a descriptive case report of a 25-year-old male who presented with right eye diminution of vision associated with ophthalmoplegia and strabismus following functional endoscopic sinus surgery (FESS) for deviated nasal septum. On examination, he had a large angle right exotropia with enophthalmos and restricted extra ocular movements. Pupils were dilated and fixed suggestive of optic neuropathy and fundus revealed a central retinal artery occlusion. Multimodal radiological imaging revealed optic nerve sheath hematoma, fracture of medial orbital wall and orbital floor along with medial rectus disinsertion with posterior discontinuation. Due to delayed presentation at our clinic, he was managed conservatively with intravenous and oral corticosteroids. The patient displayed mild improvement in ocular movement and vision. He was advised orbital reconstruction of the medial wall and floor for enophthalmos correction and cosmesis. Although a relatively safe procedure, FESS can result into varied orbital complications, including damage to the extraocular muscles, optic nerve and its vascular supply. This case report, to the best of our knowledge is the first of its kind to document ophthalmoplegia due to medial rectus disinsertion along with central retinal artery occlusion. It also highlights the perioperative risk factors and provides insight into the intraoperative signs to be cautious of during sinus surgeries

Docetaxel-Induced Bilateral Cystoid Macular Edema with a Low Cumulative Dose: A Case Report

Docetaxel and paclitaxel are taxanes. They are widely used chemotherapeutic agents that have been shown to be effective for various types of solid malignancies. Docetaxel-related bilateral toxic cystoid macular edema (T-CME) has been reported as a rare and unusual adverse reaction. We report a case of 43-year women treated for breast cancer with docetaxel and developed T-CME. She was treated with two cycles of Docetaxel 150 mg, Pertuzumab 420 mg and Trastuzumab 360mg. Three days after 2nd cycle she complained of diminution of vision. Her both eye visual acuity was 20/200. Fundus examination showed macular edema which was confirmed with SD-OCT and fluorescein angiography. After fourth cycle Docetaxel was stopped by treating physician. CME was completely resolved by three months. Several studies suggest that a cumulative dose seems necessary for the onset of the toxic effect of this drug. To our knowledge, we report the first case of Docetaxel-induced T-CME occurring within less than 1 month, with a very low cumulative dose. This suggests that no cumulative dose is needed for macular edema to appear.

Bilateral choroidal haemangioma in an otherwise normal middle aged female

Circumscribed choroidal hemangioma is a rare benign vascular tumor. It is of two types, circumsribed and diffuse. Circumscribed choroidal hemangioma is a well demarcated solitary lesion, usually situated posterior to equator, while diffuse have ill defined thickening of choroid involving more than one zone or quadrant. Patient may present with progressive diminution of vision, metamorphopsia, floaters and visual field defect. The visual symptoms are because of associated subretinal fluid, cystoid macular edema, and in long standing cases, retinal pigment epithelium changes, subretinal fibrosis and retinoschisis. It must be distinguished from amelanotic melanoma and choroidal metastasis. Investigation such as ultrasound, optic coherence tomography, fundus fluorescein angiography, indocyanin green angiography can be used to confirm the diagnosis. Multiple treatment options like transpupillary thermotherapy, photodynamic therapy, plaque brachytherapy and external beam radiotherapy.

Diagnostic dilemma- choroidal granuloma as an atypical rare presentation: A case report

Purpose: To report a rare atypical case of ocular toxoplasmosis presenting as choroidal granuloma in a young adult. Case presentation: A 16-year-old male presented with sudden diminution of vision in the right eye. The visual acuity was 6/12p in the right eye. The anterior segment examination was normal. No relative afferent pupillary defect was present. The fundus examination of the right eye showed grade 1 vitritis, a normal disc with a well circumscribed active choroidal lesion on the posterior pole, inferior to the fovea along with surrounding Subretinal Fluid (SRF) pocket. The Optical Coherence Tomography (OCT) of the right eye showed choroidal elevation with the highest dimension just inferior to the fovea, along with surrounding SRF at the fovea. Fluorescein angiography showed punctate hyperfluorescent leakage points around the lesion. Intervention: Blood hemogram was normal with a raised erythrocyte sedimentation rate. Serological screening was positive for toxoplasmosis (IgM and IgG antibodies). Human Immunodeficiency Virus (HIV) and tuberculosis (QuantiFERON Gold test) were negative. Oral medications spiramycin 500 mg three times a day for 3 weeks along with folic acid once a day was started after paediatrician consult. Result: Follow up at 1 week, the visual acuity improved to 6/9 and the choroidal elevation along with the SRF was resolving on the OCT scan. After 3 weeks of treatment the visual acuity improved to 6/6 and the fundus showed complete resolution of the choroidal granuloma along with the surrounding SRF with no residual chorioretinal scar formation. Conclusions: Our case reports a rare atypical presentation of ocular toxoplasmosis with only one more case available in the literature of ocular toxoplasmosis presenting as a posterior pole choroidal granuloma. Timely intervention lead to complete resolution of the lesion and complete restoration of the visual acuity.

Microsporidial keratoconjunctivitis - first outbreak in Japan.

Most cases of microsporidial keratoconjunctivitis are found in the Southern hemisphere. Our purpose was to investigate the first outbreak of microsporidial keratoconjunctivitis in Japan among healthy, immunocompetent soccer players from the same team during a 1-month period. This study is an observational case series. The medical records were analyzed for five cases with microsporidial keratoconjunctivitis who presented within September 2022. All five cases were males between 28 and 36 years old. These previously healthy individuals belonged to the same football team. Their eyes were considered susceptible to contaminated water or dirt from the turf at game and practice sites. All cases involved unilateral conjunctivitis, with scattered round white lesions that showed positive fluorescein staining in the corneal epithelium. All cases experienced diminution of vision in the affected eye. In three cases, direct smears showed spores of approximately 2-3μm in diameter. Polymerase chain reaction (PCR) analysis of corneal scrapes revealed partial amplification of microsporidial 18S ribosomal RNA gene in four cases. Sequences of PCR products from all four cases showed 100% identity with strains of Vittaforma corneae previously reported from an outbreak in Singapore. All cases were treated with topical therapy, including voriconazole, fluorometholone, and levofloxacin. Four eyes underwent corneal scraping. After treatment, all eyes healed without residual opacities. Only a few sporadic case reports of this disease have previously been reported in Japan. We detected V. corneae in our case series, representing what appears to be the first outbreak of microsporidial keratoconjunctivitis in Japan. Exposure to contaminated water or soil, in addition to inadequate sanitary facilities, represents a potential source of infection. Further investigations to clarify the characteristics of microsporidia seem warranted.

Misplaced Intracystic Lacrimal Implant- An Unusual Cause of Failed External Dacryocystorhinostomy.

Various techniques of dacryocystorhinostomy (DCR) by an external or endonasal endoscopic approaches are in practice of ophthalmologists and otorhinolaryngologists. The purpose of this paper is to report a case of misplaced intracystic implant in the orbit following external DCR leading to persistence of watering, diplopia and visual diminution. A thirty nine year old female patient presented with recurrent left eye pain, swelling over medial side of the left eye, watering, progressive blurring of vision and diplopia after revision external DCR. The ophthalmology examination revealed bilateral decreased vision, left side restricted extraocular eye movements, sub capsular cataract. The computed tomography dacryocystograph (CT-DCG) revealed tubular foreign body in the extra-conal space abutting the medial rectus with proximal block in the nasolacrimal duct. This is the first reported case of misplaced implant following external DCR in the literature. It may be suggested that patients undergoing intracystic larimal implant shall be on close follow up for such an occurrence later for timely intervention.

COVID-19 associated mucormycosis (CAM) in Kashan, Iran: clinical presentations, risk factors, management, and outcomes

Background This study aimed to estimate the disease burden and describe the clinical presentation, risk factors, and outcome of CAM in a single centre in Iran. Methods A case of mucormycosis was defined as one that had clinical and radiological features consistent with mucormycosis along with demonstration of the fungus in tissue via KOH mount/culture/histopathological and molecular examination. Results We report 30 cases of COVID-19 associated mucormycosis (CAM). The results of this study showed the affected age group in the range of 40–79 years (median = 65.5; IQR = 5) with women (16/30, 53%) affected more than men (14/30, 47%). Among the fungi recovered, Rhizopus oryzae had the highest frequency (79%). Out of the 30 patients, 28 (93%) patients were diabetic with 24 (80%) patients having other co-morbidities. Headache followed by retro-orbital pain, proptosis/ptosis and rapid diminution of vision was a common sequence of symptoms reported by the majority of cases. Use of mechanical ventilation (58% vs. 6%, p = 0.003), O2 required (92% vs. 50%, p = 0.024), and development of renal dysfunction during hospital stay (17% vs. 0%, p = 0.041) was significantly higher in non-survivors than survivors. Temperature (C°), PR (pulse rate), mean levels of serum creatinine, BUN, troponin, and neutrophils were significantly higher in non-survivors (p < 0.05). Besides, Albumin and PO2 were also significantly higher in survivors than non-survivors. Conclusion Despite medical and surgical treatment, the mortality rate among CAM patients is still high. Thus, concerted efforts of revamping surveillance, diagnosis and management, along with public awareness and patient education, are the requisites for managing COVID-19 and mucormycosis.

Multimodal imaging in radiation retinopathy following orbital metastasis

Background: Radiation retinopathy is a major cause of vision loss in patients receiving radiotherapy to the head and orbit. Diabetic retinopathy is included in the differential diagnosis owing to similar clinical features, including microaneurysms, cotton-wool spots, hard exudates, and macular edema. The only significant pathological difference is that radiation retinopathy spares pericytes, unlike diabetic retinopathy. Multimodal imaging helps diagnose and predict the prognosis of radiation retinopathy, which is presented in this case report.&#x0D; Case Presentation: A 55-year-old woman diagnosed with stage-4 metastatic breast carcinoma presented with gradual diminution of vision in the left eye (OS) over 5 months. Vision in the right eye was lost because of orbital radiotherapy for orbital metastasis. The patient underwent multiple sessions of chemotherapy and radiotherapy. Examination of the left eye revealed a best-corrected distance visual acuity (BCDVA) of 20/30. Fundus examination of the OS revealed multiple cotton-wool spots and retinal hemorrhages. Fundus fluorescein angiography (FFA) showed diffuse macular leakage with capillary nonperfusion. Multicolor imaging (MCI) with Spectralis™ revealed black dots in the blue and green reflectance images, corresponding to capillary dilatation on FFA. Darker dots were more evident in the infrared images. BCDVA improved to 20/20 in OS after tapering the dose of oral steroids for 2 months, with improvements in hemorrhages and cotton-wool spots. Focal laser photocoagulation was recommended for the treatment of persistent macular edema. The patient declined further treatment, was lost to follow-up, and passed away 6 months later.&#x0D; Conclusions: This case highlights the importance of multimodal imaging for the identification and classification of radiation retinopathy. MCI using SpectralisTM has been described for the first time in radiation retinopathy and can be used to complement existing imaging modalities. Future studies involving more patients and a longer follow-up duration may provide better results for the applicability of these imaging modalities in the clinical setting.

A rare case of Bardet–Biedl syndrome with BBS12 gene

We report a case of a 7-year-old girl who presented to us with diminution of vision in her both eyes since childhood. On ophthalmic evaluation, she was found to have the characteristic “sino pigmento” variety of pigmentary changes in retina. The other associated features were central obesity, polydactyly of hands and foot, syndactyly of foot, reduced hearing, and genital abnormalities. Based on these clinical features, a diagnosis of Bardet–Biedl syndrome was made. Her genetic analysis revealed the heterozygous variant for BBS12 gene. A refractive correction was done with explanation of disease. A multidisciplinary approach is required to enable them lead an improved quality of life.

Retinal detachment following lightning injury mimicking acute retinal necrosis: A case report

A 16-year-old male presented with a diminution of vision after 1 month of lightning injury. Fundus examination showed inferior retinal detachment with multiple sieve-like breaks. After pars plana vitrectomy, he developed mutton fat keratic precipitates and anterior segment inflammation. Sieve-like breaks and mutton-fat keratic precipitates (MF-KPs) led to the diagnostic dilemma of viral etiology. The patient responded well to treatment with steroids and antivirals, showing good visual recovery after silicone oil removal. Lightning strike injury–related retinal detachment can rarely mimic an acute retinal necrosis (ARN)-related retinal detachment (RD).