Spine 5.5 mm

Volume 33 • Issue 3 • September-December 2021

ISSN: 0976-6677

www.kjophthal.com

Kerala Journal of Ophthalmology ● Volume 33 ● Issue 3 ● September-December 2021 ● Pages 1-***

Mucormycosis: An overview

Phacocapsulectomy: A novel technique

Group practice – A concept doctors are shifting to

Eye to Eye Fundus Imaging

The validation of questionnaires

The Saxophone Player In Ophthalmologist's Mask

ISSN 0976-6677

Kerala Journal of Ophthalmology Editorial Board Editor

Sudha V Associate Editor

Managing Editor

Lathika Kamaladevi

Sreeni Edakhlon International Editors

Geeta Menon

Azim Siraj

Advisory Board Anantharaman Giridhar

Sahsranamam V

Charles Skariah

Arup Chakrabarti

Mahadevan K

Section Editors

Biju John C

Dhanya Cheriyath

John Davis Akkara

Sinumol S

Assistant Editors Suma Unnikrishnan

Remya Mareen Paulose

Prashob Mohan

Babitha V

Mentors Ani Sreedhar

Minu Mathen

Ganesh V Raman

Elizabeth Joseph K

Thomas Cherian

Santosh G Honavar

Mahesh G

C V Anthrayose Kakkanatt

Somasheila Murthy

Emeritus Editors Anantharaman Giridhar

Mahadevan K

Saikumar SJ

Ashok Nataraj

Mahesh G

Sasikumar S

Bastin VA

Meena Chakrabarti

Thomas Cherian

Gopal S Pillai

Narayanankutty K

TP Ittyerah

KE Eapen

NSD Raju

Krishnankutty

PI Mohan

Cover Story: Description: This is the external photography image of the right eye of a 24 year old lady who came for routine ophthalmic examination. There are multiple iris strands along the pupil, inserted in the collarette, resembling a flower. Persistent pupillary membrane is a common congenital ocular anomaly and is a remnant of anterior tunica vasculosa lentis. Although the patient had a similar picture bilaterally, her vision was 6/9 in both the eyes, due to stenopeic effect. Contributed by: Dr. Hridya Mohan, Medical Officer, Cataract Services, Aravind Eye Hospital, Coimbatore Kerala Journal of Ophthalmology / Volume 33 / Issue 3 / September-December 2021

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Kerala Journal of Ophthalmology Volume 33  Issue 3

Contents

September-December 2021

Editorial Connect, collaborate, contribute, and create V Sudha

239

Guest Editorial Mucormycosis: An overview Viji Rangarajan, Anandhalakshmi Subramanian

242

Perspectives Group practice – A concept doctors are shifting to Babu Krishnakumar

249

Ophtha Insta Asymptomatic Goldenhar syndrome in an adult Bharat Gurnani, Kirandeep Kaur

252

Major Review Rhino-orbito-cerebral mucormycosis in COVID 19 patients: Understanding the pathophysiology Deepsekhar Das, Mandeep Singh Bajaj, Sujeeth Modaboyina, Sahil Agrawal

254

Research Methodology The validation of questionnaires Praveen K. Nirmalan

260

Original Articles Ocular morbidity due to the usage of handheld digital devices: A population‑based cross‑sectional study using a validated questionnaire M. Manju

263

Central corneal thickness, anterior chamber depth, and axial length in patients with type II diabetes mellitus Namrata Sasalatti, Rajani Kadri, Sudhir Hegde, Ajay A. Kudva, P. Devika, Akansha Shetty, Prerana Shetty

269

Multidose bevacizumab (Avastin) vial microbial safety: A real‑life scenario Battu Aneesha Priya, Sheshadri Vishnu Mahajan, M. Ramesh Chandra

274

A cross sectional study of visual field patterns in advanced primary open‑angle glaucoma Anisha Tresa Augustin, K. C. Rajini, V. Sudha

278

Digital eye strain among undergraduate medical students during the COVID‑19 pandemic: A cross‑sectional survey Ferzana Mohammed, Sandhya Somasundaran, Jyothi Poothatta

284

Optic nerve head‑retinal nerve fiber layer analysis with spectral‑domain optical coherence tomography of ethambutol‑induced ocular toxicity in patients on a daily regime of anti‑tubercular therapy Sanaa Mohammed Konnakkodan, Charmaine Bridgette Solomon, Padma B. Prabhu, A. Arun Kumar

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Analysis of foveal microvascular abnormalities in various stages of diabetic retinopathy using optical coherence tomography angiography B. C. Hemalatha, B. N. Kalpana, Y. D. Shilpa, B. Ravi, Vijayalaxmi R. Argekar, H. R. Hithashree, V. Sahana Dixith

299

Clinical profile of silicon oil-induced ocular hypertension: A prospective study Nishat Sultana Khayoom, Rose Mary George

306

Comparative study of intracameral lidocaine and topical mydriatics in pupil dilation during phacoemulsification K. K. Shilpa Sunil,   N. V. Latha

311

Decision making in pterygium surgery: Our experience noting the length of pterygium Anjali Lita Roche, Narendra Panduranga Datti, Indu Govind, Ravikiran Kamunuri

316

Surgical Corner Phacocapsulectomy: A novel technique to deal with extensive capsular fibrosis Narayan Bardoloi, Sandip Sarkar

322

Case Reports Trochlear nerve palsy with contralateral Horner’s syndrome: A rare presentation post trauma Remya Edachery

326

Capillary hemangioma masquerading as a dermoid cyst Meenakshi Wadhwani, Shubhangi Kursange, Nidhi Mahajan

331

The damaging shield: An incapacitating presentation of vernal keratoconjunctivitis Mamta Agrawal, Reshma Ramakrishnan, Choudhary Ayushi

333

Abnormal electrophysiology in a case of torpedo maculopathy Manoj Soman, Akshaya Ashok, Ashwin Mohan, Unnikrishnan Nair

337

Nonpigmented immobile large vitreous cyst: A rare case report  Priyanka Gupta, Harsh V. Garg

341

Long‑term linezolid: Unnerving the nerves? Gayatri Raja Bhonsale, Sayali Santosh Amberkar

344

The eyes show what the brain has: A case report on neuromyelitis optica Ayushi Choudhary, Reshma Ramakrishnan, Mamta Agrawal

349

A case of bilateral sequential optic neuropathy in a young adult post hemodialysis Harsha Sameer Pagad, Rishwa Hariyani, Nita U. Shanbhag

353

Superficial variant of granular corneal dystrophy‑description of four cases Aneeta Jabbar, B. Radharamanan

356

Photo Essay When iron hits; iris safeguards, lens surrenders Prateek Jain, Anshuman Pattnaik

360

Innovations Eye to Eye Fundus Imaging with Ophthalmic Wand - Anytime! Anywhere!! Vishnu Teja Gonugunta, Chinmayee Pabolu, Krishnagopal Srikanth, Kirti Nath Jha

362

History Corner Dr. Charles Kelman: The Saxophone Player In Ophthalmologist’s Mask C. Biju John

365

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Journal Review Jincy Mariya Paul

370

PG Corner iTrace aberrometry ‑ Identifying occult imperfections in the visual system Bharat Gurnani, Kirandeep Kaur

373

Letters to the Editor Prevalence and risk factors for refractive errors in Kerala Mallika O. U, Reesha K. R, S. Jainy, M. S. Sunil

384

Prevalence and risk factors for primary glaucoma in Kerala – The need for information A. V. Asha, T. U. Laly, Liji Menon, M. G. Greeshma, K. Samyuktha Sadasivan, A. R. Arya, Risha Raveendran, Naveena

386

Has COVID‑19 changed long‑term clinical practice – The new abnormal? Saloni Gupta, Sahil Agrawal

388

Comment on “the champion runner who became the forerunner in ophthalmic surgery training” Vinodkumar Nalapat Venugopal

390

The indirect effect of emerging infectious diseases such as coronavirus disease 2019 on myopia progression Ali Nouraeinejad

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Kerala Journal of Ophthalmology / Volume 33 / Issue 3 / September-December 2021

Kerala Journal of Ophthalmology General Information The journal Kerala Journal of Ophthalmology (KJO), the official publication of Kerala Society of Ophthalmic Surgeons (KSOS) is published as print and online journal.

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Permissions For information on how to request permissions to reproduce articles/ information from this journal, please visit www.kjophthal.com Disclaimer The information and opinions presented in the Journal reflect the views of the authors and not of the Journal or its Editorial Board or the Publisher. Publication does not constitute endorsement by the journal. Neither the Kerala Journal of Ophthalmology nor its publishers nor anyone else involved in creating, producing or delivering the Kerala Journal of Ophthalmology or the materials contained therein, assumes any liability or responsibility for the accuracy, completeness, or usefulness of any information provided in the Kerala Journal of Ophthalmology, nor shall they be liable for any direct, indirect, incidental, special, consequential or punitive damages arising out of the use of the Kerala Journal of Ophthalmology. The Kerala Journal of Ophthalmology, nor its publishers, nor any other party involved in the preparation of material contained in the Kerala Journal of Ophthalmology represents or warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from the use of such material. Readers are encouraged to confirm the information contained herein with other sources. Address Editorial Office Dr. Sudha V MS (Ophthalmology), DNB (Ophthalmology) Additional Professor, Govt.Medical College, Thrissur Kerala, India. E-mail: [email protected] Phone - 9446619280 Published by Wolters Kluwer India Private Limited. A-202, 2nd Floor, The Qube, C.T.S. No.1498A/2 Village Marol, Andheri (East), Mumbai - 400 059, India. Phone: 91-22-66491818 Website: www.medknow.com Printed at: Nikeda Art Printers Pvt Ltd. Bhandup (W), Mumbai, India.

Kerala Journal of Ophthalmology / Volume 33 / Issue 3 / September-December 2021

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Editorial

Connect, collaborate, contribute, and create “No one is big enough to be independent of others.” ‑Will Mayo As this Editorial team reaches the end of its 2 year tenure, I wish to thank each and every member of the team for the excellent teamwork and cooperation I received during this time. Selecting articles, reviewing, writing up sections, proofreading, and encouraging others to contribute, were all done in a timely and effective manner. Hopefully, we have together been able to raise the standards of our Journal. The encouragement and effective suggestions I received from my senior colleagues, timely reviews by expert reviewers from KSOS and outside, played a very important role in keeping the momentum going.

COLLABORATIONS IN OPHTHALMOLOGY Being able to take care of the sight of a patient is both a responsibility and a privilege. Because this is our ultimate goal: to eliminate blindness and visual impairement. Many useful examples of cooperation have been seen in Ophthalmology.

The World Health Organization (WHO) recognizes that collaborative practice strengthens health systems and improves health outcomes, and is an innovative strategy that will play an important role in mitigating the global health workforce crisis. The Framework for Action on Interprofessional Education and Collaborative Practice is the product of the WHO Study Group on this practice.[1]

Research Collaboration is vital in driving forward research and innovation seeking to develop solutions to refine the diagnosis, management, and treatment of patients with eye diseases. There is a well‑identified need for patient‑oriented clinical research and this can only be achieved by creating active collaboration between academic centers with competence for clinical research, with support by an infrastructure that provides appropriate management of clinical trials at a realistic cost. In Ophthalmology, the example was set by the Diabetic Retinopathy Clinical Research (DRCR. net) Retina Network in the USA, formed in 2002 through a National Eye Institute and National Institute of Diabetes and Digestive and Kidney Diseases‑sponsored cooperative agreement. The objective was to develop a collaborative network to facilitate multicenter clinical research on Diabetic Retinopathy and Diabetic Macular Edema, and has now been expanded to include research on other retinal diseases. It used the combined strengths of academic and community retina sites in the infrastructure as well as created opportunities for industry collaboration while maintaining rigorous academic independence from pharmaceutical interests.[2] Since 2002, the DRCR. net has initiated and completed numerous multicenter studies in DR with over 160 participating sites and 500 physicians throughout the United States and Canada.

Collaboration is evident when health‑care professionals communicate with each other, assume complementary roles to cooperatively work together, and share responsibility for problem‑solving and decision‑making. Specific collaborative activities include sharing of information, discussion of complicated cases, and referrals to colleagues. The developing concept of Group Practice and its advantages has been highlighted by the President, KSOS, in the following pages of this journal issue.

Multicenter Data Retrieval Data from various sources can be integrated into a common registry and provide important information. Useful applications can be derived too from these. Data derived from the Sight Outcomes Research Collaborative Ophthalmology Data Repository, which captures electronic health record data of all patients receiving any eye care at academic medical centers, was used for developing an algorithm useful in triaging patients in the COVID pandemic based on glaucoma severity and progression risk by identifying patients whose

In my final editorial, I would like to highlight this extremely important concept of Teamwork and Collaboration. The concept of Networking for individual professional upliftment is gaining popularity. However, if we can cooperate with each other for the benefit of Ophthalmology as a whole, and patient treatment patterns, in particular, we reach nearer to our shared goal of reducing visual disability. EVERYBODY WINS

© 2021 Kerala Journal of Ophthalmology | Published by Wolters Kluwer - Medknow

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Sudha, et  al .: Teamwork and collaboration

appointments could safely get postponed and facilitated prioritization of appointments for rescheduling.[3] Clinical Practice Guidelines We are beginning to work together to develop consensus statements about eye care and train ourselves on how to use best practice guidelines. An international, expert‑led consensus initiative was set up by the Collaborative Ocular Tuberculosis Study group to develop systematic, evidence, and experience‑based recommendations for the treatment of ocular TB using a modified Delphi technique process.[4] Sharing Knowledge And Expertise Improving education and training to raise standards in Ophthalmology worldwide[5,6] is being followed by many important organizations, and is best exemplified by the online academic resource, EyeWiki, which is a collaboration between the American Academy of Ophthalmology and multiple societies.[7] Networking for Professional Career Advancement There is a critical need to help ophthalmologists maintain their competency and learn new skills, forging valuable relationships with peers. Organized mentorship programs can play a key role in fostering the development of careers in ophthalmology.[8] Stronger personal relationships can nurture innovative strategies with colleagues, engage new energy, and maintain momentum when obstacles seem overwhelming. Public Education Public–private partnerships can improve population health by advancing public health strategies and policies, improving public health education and advocacy, fostering trust and collaboration among sectors and stakeholders, and improving access to health care.[9] Newer Technologies A universal artificial intelligence (AI) platform developed for collaborative management of cataracts involving multilevel clinical scenarios explored an AI‑based medical referral pattern to improve collaborative efficiency and resource coverage. It showed robust diagnostic performance and effective service for cataracts.[10]

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Learning how to work in teams, brainstorming on issues, and networking with the right people can improve our individual practices. Publications based on multicentric research can provide data on comprehensive real‑life effectiveness of various treatment strategies, especially in resource‑poor regions where implementing strict guidelines may not be feasible. Innovations like using AI in Ophthalmology are made possible through collaboration among scientists, medical professionals, and technological experts. Thus, this concept needs to be nurtured and encouraged by all professional societies. Clarity and transparency in the collaboratorship process are essential in nurturing these networks and carrying them forward in future practice. Signing off with best wishes to the incoming Editorial team …… V Sudha Department of Ophthalmology, Government Medical College, Thrissur, Kerala, India Address for correspondence: Dr. V Sudha, Department of Ophthalmology, Government Medical College, Thrissur, Kerala, India. E‑mail: [email protected]

REFERENCES 1.

2.

3.

4.

5.

6.

7.

World Health Organization. Framework for Action on Interprofessional Education and Collaborative Practice. World Health Organization; 2‎ 010. Available from: https://apps.who.int/iris/handle/10665/70185.  [Last accessed on 2021 Sep 15]. Sun  JK, Jampol  LM. The diabetic retinopathy clinical research network (DRCR.net) and its contributions to the treatment of diabetic retinopathy. Ophthalmic Res 2019;62:225‑30. Bommakanti NK, Zhou Y, Ehrlich JR, Elam AR, John D, Kamat SS, et al. Application of the sight outcomes research collaborative ophthalmology data repository for triaging patients with glaucoma and clinic appointments during pandemics such as COVID‑19. JAMA Ophthalmol 2020;138:974‑80. Agrawal R, Testi I, Mahajan S, et al. The Collaborative Ocular Tuberculosis Study (COTS) Consensus (CON) Group Meeting Proceedings [published online ahead of print, 2020 Apr 6]. Ocul Immunol Inflamm. 2020;1-11. doi:10.1080/09273948.2020.1716025. The Royal College of Ophthalmologists. “International Strategy.” Available from: https://www.rcophth.ac.uk/professional‑resources/ international‑strategy/. [Lastaccessed on 2021 Sep 10]. Cybersight. “Consultation and Mentorship from International Experts.” Available from: https://cybersight.org/consultation/. [Last accessed on 2021 Sep 10]. EyeWiki: Main Page New – EyeWiki. Available from: https://eyewiki. org/EyeWiki%3AMain_Page_New. [Last accessed on 2021 Sep 10].

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Sudha, et   al.: Teamwork and collaboration

8.

Women in Ophthalmology. “Women in Ophthalmology | A Powerful Collective of Women Ophthalmologists.” Available from: https://www. wioonline.org/. [Last accessed on 2021 Sep 10]. 9. Nishtar S. Public – Private ‘Partnerships’ in health – A global call to action. Health Res Policy Syst 2004;2:5. 10. Wu X, Huang Y, Liu Z, Lai W, Long E, Zhang K, et al. Universal artificial intelligence platform for collaborative management of cataracts. Br J Ophthalmol 2019;103:1553‑60.

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. Submitted: 15-Sep-2021 Accepted: 16-Sep-2021 Published: 08-Dec-2021

Access this article online Quick Response Code Website: www.kjophthal.com

DOI: 10.4103/kjo.kjo_194_21

How to cite this article: Sudha V. Connect, collaborate, contribute, and create. Kerala J Ophthalmol 2021;33:239-41.

Kerala Journal of Ophthalmology / Volume 33 / Issue 3 / September-December 2021

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Guest Editorial

Mucormycosis: An overview

ABSTRACT Rhino‑orbital mucormycosis is a life‑threatening opportunistic fungal infection, which affects mainly immunocompromised hosts. It is commonly caused by ubiquitous fungi belonging to the order Mucorales, family Mucoraceae, which is also commonly known as the black fungus among the general population. The prevalence of mucormycosis (approximately 0.14 cases/1000 population) in India is about 80 times higher than in other developed countries. Despite aggressive treatment with surgical debridement and timely antifungal administration, the overall mortality rate is high. COVID 19 pandemic has led to an increase in the incidence of rhino‑orbital mucormycosis. A multidisciplinary approach with early diagnosis and timely treatment with good control of glycemic levels, judicious use of steroids, and addressing immune status of patients helps in reducing the mortality and aids in improving survival rates of mucormycosis patients. Keywords: Antifungal, COVID‑19, immunocompromised, Mucorales, mucormycosis

INTRODUCTION

EPIDEMIOLOGY

Rhino‑orbital cerebral mucormycosis (ROCM) or phycomycosis is a life‑threatening, angioinvasive disease caused by fungi of the order, Mucorales. It occurs mainly in immunocompromised conditions including patients with uncontrolled diabetes mellitus, hematological malignancies, postorgan transplant recipients on immunosuppressive therapy, and patients on iron overload therapy, hemodialysis, and chemotherapy who are at increased risk of acquiring mucormycosis.[1] It may also affect immunocompetent patients following trauma or burns.[2] Clinically classified as rhinocerebral, pulmonary, gastrointestinal, and disseminated. The incidence of mucormycosis has increased markedly in the settings of COVID‑19 in India. It has been declared as an epidemic and a notifiable disease in many states.

The exact incidence of mucormycosis is unknown. Globally, the prevalence of mucormycosis varied from 0.005 to 1.7/million population. The estimated prevalence of mucormycosis is 70% higher in India than in developed countries.[3] The high prevalence rate may be due to the increased presence of Mucorales in community, hospital environment, and immunocompromised state, especially uncontrolled diabetes. Association of COVID‑19 with a recent increase in the incidence of mucormycosis is possibly due

Submitted: 17‑Aug‑2021 Accepted: 20‑Aug‑2021

Revised: 18‑Aug‑2021 Published: 08-Dec-2021

Access this article online Quick Response Code Website: www.kjophthal.com

DOI: 10.4103/kjo.kjo_179_21

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Viji Rangarajan, Anandhalakshmi Subramanian Department of Orbit and Oculoplasty, Aravind Eye Hospital, Coimbatore, Tamil Nadu, India Address for correspondence: Dr. Viji Rangarajan, Department of Orbit and Oculoplasty, Aravind Eye Hospital, Coimbatore ‑ 641 014, Tamil Nadu, India. E‑mail: [email protected] This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

For reprints contact: [email protected]

How to cite this article: Rangarajan V, Subramanian A. Mucormycosis: An overview. Kerala J Ophthalmol 2021;33:242-8.

© 2021 Kerala Journal of Ophthalmology | Published by Wolters Kluwer - Medknow

Rangarajan and Subramanian: Mucormycosis

 – An overview

to severe acute respiratory syndrome coronavirus‑2 causing impaired cell‑mediated immunity and lymphopenia leading to a reduction in CD4 and CD8 cells.[4]

b. Low‑grade fever c. Localized facial pain d. Myalgia.

CAUSATIVE ORGANISMS

Ocular manifestations a. Ocular pain b. Periorbital edema c. Proptosis [Figure 2] d. Ptosis [Figure 3] e. Diplopia f. Ophthalmoplegia [Figure 4] g. Discoloration of skin in the periocular region. h. Numbness in the infraorbital region i. Defective color vision j. Sudden blindness due to CRAO, thrombosis of posterior ciliary arteries, infarction of the intraorbital part of the optic nerve, or direct fungal invasion of intracranial part of the optic nerve or optic chiasma[9] [Figure 5].

Mucorales are saprophytic fungi commonly found in decaying organic matter, soil, and air. Rhizopus, Lichtheimia, Cunninghamella, and Rhizomucor are the common pathogenic species causing mucormycosis in India. Rhizopus arrhizus, a nonseptae filamentous fungi, is the most common cause of mucormycosis in India. Apophysomyces variabilis is the second common isolated agent. Lichtheimia species contributes about 0.5% to 13% of cases from India.[5] Rare pathogens such as Saksenaea erythrospora, Mucor irregularis, and Thamnostylum lucknowense were also reported.[6] RISK FACTORS Mucormycosis is a rare disease, but several immunocompromised conditions can predispose it. Uncontrolled diabetes is the most common underlying risk factor for contracting mucormycosis and increases the severity of COVID‑19. Hyperglycemia causes glycosylation of transferrin and ferritin and reduces iron binding which leads to increase in free iron levels. It enhances the expression of glucose‑regulator protein78 of endothelial cells and Mucorales receptor core protein homologs, enabling angioinvasion, hematogenous dissemination, and tissue necrosis.[7] Severe neutropenia, steroid therapy, patients on prolonged ventilatory support, pulmonary tuberculosis, hematological malignancies, solid organ transplantations, malnutrition, autoimmune disease, HIV infection, and usage of immunosuppressant[8] drugs are the other important risk factors to be considered. ETIOPATHOGENESIS

Nasal symptoms a. Nasal block b. Nasal bleeding c. Blackish or blood‑tinged nasal discharge d. Post nasal drip. Oral manifestations a. Toothache, loosening of teeth b. Loss of sensation or numbness over the hard palatal region c. Blackish discoloration of buccal mucosa – Eschar formation [Figure 6] d. Perforation over the palatal region. Pulmonary manifestations a. Fever b. Cough with progressive dyspnea c. Pleuritic chest pain.

Saprophytic fungi are rapidly growing fungi, which release a large number of spores in the environment. Inhalation of sporangiospores by the hosts gets colonized in oral mucosa, nose, throat, and paranasal sinuses. In immunocompromised individuals, phagocytosis is impaired, thus fungal spores undergo proliferation with resultant angioinvasion. A rapid progression occurs which leads to pansinus involvement followed by the hematogenous dissemination to bony walls of the nose, palate, orbit, and finally to the brain resulting in extensive necrosis and tissue ischemia [Figure 1].

Cutaneous and soft tissue manifestations a. Erythema with induration b. Black eschar at trauma/puncture site c. Muscle pain.

CLINICAL PRESENTATIONS

Cerebral involvement a. Altered sensorium b. Hemiparesis c. Seizures.

Generalized symptoms a. Severe headache

Gastrointestinal manifestations a. Fever b. Bleeding per anus c. Abdominal mass d. Intestinal perforation.

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Rangarajan and Subramanian: Mucormycosis

 – An overview

Figure 1: Pathogenesis of mucormycosis (Image courtesy: id.theclinics. com)

Figure 2: Left eye proptosis with chemosis

Figure 3: Right eye complete ptosis

Figure 4: External ophthalmoplegia

Figure 5: Fundus picture showing cherry red spot

INVESTIGATIONS

Figure 6: Eschar over the hard palate

Laboratory investigations include 1. Complete blood count 2. Blood sugar levels including fasting blood sugar, postprandial blood sugar, and HBA1C 3. Renal function test 244

4. 5. 6. 7.

Liver function test Serum electrolytes Serology–HIV, hepatitis B surface antigen, HCV Serum ferritin.

Kerala Journal of Ophthalmology / Volume 33 / Issue 3 / September-December 2021

Rangarajan and Subramanian: Mucormycosis

 – An overview

HISTOPATHOLOGY AND DIRECT MICROSCOPY Definitive diagnosis is achieved by the histopathological examination of the specimen collected by a high nasal swab or diagnostic endoscopy during the endoscopic sinus debridement of the involved tissue. The fungal invasion may be patchy, so multiple biopsies from the active areas of infection may be required. Microscopical analysis of the specimen using 10% potassium hydroxide mount shows nonseptate branched fungal hyphae branching at right angles[9] which provides presumptive diagnosis. Calcofluor white, Grocott‑Gomori’s methenamine silver, and periodic acid–Schiff are the special stains helpful in illustrating the presence and morphology of the fungus [Figures 7and 8].[10]

Figure 7: Periodic acid–Schiff stain highlighting the presence of branching hyphae

CULTURE Surgically debrided or biopsied specimen should be cultured for the identification of the fungus to genus and species level and for antifungal susceptibility. Specimens should be collected aseptically in sterile containers and transported to the laboratory within 2 h. Samples are cultured on Sabouraud dextrose agar without cycloheximide, brain–heart infusion agar, or potato dextrose agar. Fungal cultures should be examined twice weekly for 4 weeks before reporting it as negative. It usually takes 2–3 days for the colonies to appear. Identification is based on macroscopic dirty white, fluffy, cotton‑like colonies and microscopic morphology and growth temperature which is usually 30°C and 37°C [Figure 9].

Figure 8: Grocott‑Gomari’s methenamine silver stain showing the invasion of mucor

IMAGING Computed tomography (CT) and magnetic resonance imagining (MRI) help in the early diagnosis of ROCM. Imaging shows the changes proportional to the extent of the fungus invasion of the affected tissue.[11] CT scans demonstrate mucosal thickening and a lack of air–fluid level in the infected sinus in the early stages. In later stage, it demonstrates the destruction of the medial orbital wall and the rectus muscles invasion, orbital apex, and involvement of ipsilateral cavernous sinus.[12,13] Compared to CT scans, MRI allows for better visibility of orbital soft tissue invasion, infratemporal fossa involvement, intracranial structures, perineural invasion, and vascular obstruction.[14,15] Fungal elements in MRI cause low intensity due to mucosal involvement and lack of enhancement of the mucosa is caused by its angioinvasive nature. MRI variables such as T1‑ and T2‑weighted images show devitalized mucosa appearing as contiguous foci of infection

Figure 9: Culture plate showing dirty white, cotton‑like colonies

causing non‑enhancing tissue, which appears as “Black turbinate sign.”[16] In case of progressive ROCM disease, MRI shows hyperintense sinus wall, T2‑W hyperintense

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 – An overview

INDUCTION THERAPY • Drug of choice: Liposomal amphotericin B – Intravenous (IV) administration • Dose for sino‑orbital involvement – 5 mg/kg/day • Dose for cerebral involvement – 10 mg/kg/day. INJECTION MODE AND MONITORING

Figure  10: Image shows nonenhancing right inferior turbinate  (black turbinate sign). Bilateral orbital cellulitis and focal cerebritis of basifrontal lobes (R > L) seen

lesion extending from paranasal sinus along orbital apex into intracranial structures, and narrowing or slow flow in the ipsilateral internal carotid artery [Figure 10]. DIAGNOSIS Possible rhino‑orbital cerebral mucormycosis Patients with typical signs and symptoms with a history of COVID treatment, DM, on steroid therapy, supplemental oxygen, and ventilator support. Probable rhino‑orbital cerebral mucormycosis Signs and symptoms along with diagnostic nasal endoscopy findings (or) contrast‑enhanced MRI or CT. Proven rhino‑orbital cerebral mucormycosis Clinicoradiological features along with microbiological confirmation (on direct microscopy) or culture/HPE/molecular diagnostics.[17]

• Test dose: Injection liposomal amphotericin B 1 vial (50 mg) to be diluted in 12 ml of the diluent and 0.25 ml (1 mg) of solution made, to be mixed in 100 ml dextrose and to be infused in 30 min. Assessment for fever and allergic reactions is mandatory • Prehydration: Five hundred milliliter normal saline administered over 30 min with 1 ampule (20 mmol) potassium chloride • Therapy: 5 mg–10 mg/kg/day amphotericin B in 500 ml DS with 10 units of human insulin regular over 3 h • Post hydration: Five hundred milliliter normal saline administered over 30 min. After every dose of amphotericin B, renal function test with serum electrolytes has to be monitored. If liposomal amphotericin B is unavailable, amphotericin B deoxycholate or amphotericin B lipid complex, which is less expensive can be used, but found to cause systemic toxicity. In conditions where amphotericin is contraindicated 1. Isavuconazole IV 200 mg thrice daily for 2 days ‑>200 mg once from day 3 for 4–6 weeks (or) 2. Posaconazole IV 300 mg twice daily on day 1 – >300 mg once from day 2 for 4–6 weeks. RETROBULBAR TRANSCUTANEOUS AMPHOTERICIN

MEDICAL MANAGEMENT

Transcutaneous retrobulbar injection of amphotericin B Injection into the retrobulbar space has been described as a minimally invasive, globe‑sparing treatment for orbital mucormycosis.[19] Since lidocaine or bupivacaine is inflammatory, amphotericin B must be reconstituted with sterile water. Patients are anesthetized with a retrobulbar injection of 2–3 ml to avoid medication‑induced pain. After 5 min, a 24‑gauge retrobulbar needle was used to deliver 1 ml of liposomal amphotericin B to the retrobulbar space.[20]

Rhino‑orbital mucormycosis should be treated as an emergency without delay in initiation of therapy. Prompt antifungal administration, correction of underlying risk factor such as hyperglycemia, acidemia and aggressive surgical intervention is essential for good prognosis.[18]

Indications The indications for retrobulbar injection are mild orbital involvement, patients presenting with ROCM with good vision acuity, without apical/CNS spread. It can also be administered along with IV amphotericin.

STAGING • • • •

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Stage 1: Involvement of nasal mucosa Stage 2: Involvement of PNS Stage 3: Involvement of orbit Stage 4: Involvement of central nervous system (CNS).

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Dose One milliliter of 3.5 mg/ml Follow‑up therapy IV liposomal amphotericin B‑5–10 mg/kg/day for a minimum of 4 weeks. Step down therapy IV isavuconazole 200 mg thrice daily for 2 days followed by 200 mg once from day 3 or IV posaconazole 300 mg twice daily on day 1 followed by 300 mg once from day 2 administered for 3–6 months (or) for a minimum of 6 weeks till evidence of clinical or radiological regression is noted. SURGICAL MANAGEMENT In case of predominant sinonasal with no (or) limited orbit involvement/vision preserved Functional endoscopic sinus surgery is indicated to reduce the fungal load from the sinuses with irrigation with amphotericin B 1 mg/ml ± turbinectomy ± palatal resection ± medial orbital wall resection depending on the extension of the disease. In case of disease progression, worsening of orbital component in 2 h/day were at 1.86 times higher risk of getting ocular morbidities than others. In HHDD users asthenopic symptoms were more compared to ocular surface‑related problems. Conclusion: This study demonstrates that the long and continuous usage of HHDD has a significant association with ocular morbidity. Further studies are needed to analyze and ascertain whether the existing treatment algorithm and ocular ergonomics for computer users are enough for individual or combined usage of HHDD. Keywords: Computer vision syndrome, handheld digital devices, ocular morbidity

INTRODUCTION

prevalence of DES is estimated to range from 20% to 90% among visual display unit users.

Digital devices (DD) has become an integral part of our life owing to their ever‑increasing significance in making our life easier. Most used DD are mobile phones, computers (desktops and laptops), E‑Readers, Game consoles, etc.[1] DD could be broadly classified into two types – hand held DD (HHDD) which are usually used within 30 cm from the eye and non HHDD (NHHDD) which are used at a distance of more than 30 cm from the eye.[2] Digital eye strain (DES) is a condition characterized by visual disturbance, ocular discomfort caused by DD. Symptoms of DES include ocular fatigue, watering of eyes, blurring of vision, burning sensation, redness, and double vision.[3] The Submitted: 30-Dec-2020 Accepted: 23-Mar-2021

M. Manju Department of Ophthalmology, Thrikkakara Municipal Co‑operative Hospital, Ernakulam, Kerala, India Address for correspondence: Dr. M. Manju, Department of Ophthalmology, Thrikkakara Municipal Co‑operative Hospital, Seaport Airport Road, Near Collectorate Kakkanad (PO), Ernakulam ‑ 682 030, Kerala, India. E‑mail: [email protected]

Revised: 06-Feb-2021 Published: 08-Dec-2021

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Due to the recent technological advancements, HHDD are able do most of the things previously done by NHHDD. This would have a profound effect on ocular health, in general, owing to the significant reduction in the distance from the eye to the screen. Most of the initial research in relation to

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www.kjophthal.com For reprints contact: [email protected] DOI: 10.4103/kjo.kjo_211_20

How to cite this article: Manju M. Ocular morbidity due to the usage of handheld digital devices: A population-based cross-sectional study using a validated questionnaire. Kerala J Ophthalmol 2021;33:263-8.

© 2021 Kerala Journal of Ophthalmology | Published by Wolters Kluwer - Medknow

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Manju: Ocular morbidity due to handheld digital devices

the usage of DD were based on computers (NHHDD). HHDD differs from computers in many parameters like viewing position and distance, font size, luminance, pattern of use, etc.[4] Hence, there can be a difference in the morbidity profile of HHDD in comparison to NHHDD. Thus, it is important to exclusively study the ocular morbidity profile of HHDD, to design specific ergonomic practices and treatment protocols. The authors evaluated available literature for the effects of HHDD on binocular vision, blinking, and ocular surface to consider potential aetiologies. MATERIALS AND METHODS Study population The general population above 15 years of age willing to participate in the study were considered irrespective of their nativity, race, or gender.

2. 3. 4.

5.

6.

statistician. They ensured that the survey does not contain any errors such as leading, confusing, or double‑barrelled questions Pilot study was done using 25 participants Data obtained in a spreadsheet was checked for any inconstancies Principal components analysis (PCA) was done to identify underlying components and themes that are being measured by survey questions. Kaiser‑Meyer‑Olkin Measure of Sampling Adequacy value obtained was 0.62. Since the PCA value was above 0.6, it was accepted Internal consistency was checked by the test‑retest method. Done with 50 participants and the reliability of the questions were established by statistical analysis Revision of the questions and extension of the survey was done.

d = Absolute precision.

The data collected from the patients were recorded and analyzed. Descriptive analysis of the population’s characteristics was carried out. Categorical variables were expressed as counts and percentages. Univariate analysis using Chi‑square test was done to find out the association between the various determinants of different kinds of morbidities. Data set was divided into two depending on whether the participant used HHDD for 2 h on a day or more. Then these two groups were compared regarding the ocular morbidities. Odds ratio and 95% confidence interval were measured. Data were analyzed using IBM Corp. Released 2019. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp [Table 1].

The sample size obtained was –310

RESULTS

Inclusion criteria Participants from the general population who voluntarily filled the questionnaire.

Demographic characteristics of the population 534 participants enrolled in the study out of which those who use laptops or desktops for more than 2 h were excluded. Data from the remaining 327 participants was analyzed. 181 participants (55.4%) were males and 146 participants (44.6%) were females. 152 participants (46%) were of the 26–35 years age group. 195 participants (59%) had any one of the ocular morbidities studied.

Study design Population‑based study using a validated survey questionnaire The sample size was calculated using the formula Z1-2 α / 2 p(1- p) (1) d2 where Z1–α/2 = 1.96 n=

p = Expected proportion

Exclusion criteria • Participants under the age of 15 • Participants who were using computers for more than 2 h a day. Data were collected using an online questionnaire with 13 multiple choice questions related to the usage of the DD. The questionnaire was circulated in social media and the resulting data maintained in a spreadsheet. Validation of the questionnaire Validation of questionnaire was done by 6 step validation method. 1. Face validity of the questionnaire was established by 2 independent evaluators‑a subject expert and a 264

Participants in the age group 26–35 years constituted 47% of the morbidity reported. Among the participants with morbidities 59% were male and 41% were female. The maximum number of participants had neck pain (20%) followed by eye strain or fatigue (19%). 73% of the participants with morbidities were using HHDD for more than 2 h a day [Table 2]. About 48% of the participants with morbidity were not aware about the type of screen available in their HHDD. 27% of

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Manju: Ocular morbidity due to handheld digital devices

Table 1: Validated questionnaire 1. Age group: (a) 15‑25 (b) 26‑35 (c) 36‑45 (d) 46‑55 (e) 56‑65 (f) 66‑75 (g) Above 75 2. Sex: (a) Male (b) Female (c) Other 3. How long are you using HHDD: (a) 6 ≤6 >2 ≤2 Watching movies, videos, playing video games Work, browsing, chatting, social media, reading 050 75100 5075 Yes No Yes No

Daily usage of HHDD (h) Purpose Brightness level (%)

Continuous usage of HHDD >2 h Spectacles

Yes, n (%)

No, n (%)

OR (95% CI)

P

117 78 144 51 38 157 144 11 40 71 124 58 137

90 42 78 54 20 112 95 8 29 31 101 31 101

0.700 (0.439-1.114)

0.132

1.950 (1.2193.132)

0.0053*

1.355 (0.7489-2.4531)

0.315

0.996 (0.3564-2.7883)

0.9952

1.865 (1.1348-3.0666)

0.0139*

1.365 (0.82292.2665)

0.2279

*Statically significant association. HHDD Hand held digital devices, OR – Odds ratio, CI – Confidence interval

the participants with morbidity were using HHDD with LCD screens [Figure 1]. Among the participants with morbidities 45% of them had refractive errorr as a co‑morbidity. Participants with cumulative HHDD use for >2 h/day were at 1.95 times of higher risk and participants with continuous usage of HHDD for >2 h/day were at 1.86 times higher risk of getting ocular morbidities than others. The usage of HHDD for more than 6 years showed an increase in morbidities, although the P value is not statistically significant. 80% of the participants with morbidities used HHDD for working and social media usage. Eye‑related problems were more prevalent among those who used HHDD for working and reading than those who used it for watching videos and playing games. 63% of the participants in the study were using HHDD with a brightness