Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : February | Volume : 17 | Issue : 2 | Page : NC08 - NC12 Full Version

Prevalence of Ophthalmic Manifestations in COVID-19 Positive Indoor Patients during Second Wave at Rural Tertiary Care Hospital of Gujarat: A Prospective Observational Study


Published: February 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/59956.17463
Dhwani Satishbhai Mehta, Harsha Chetan Jani, Jane Manishkumar Mehta

1. Junior Resident, Department of Ophthalmology, Shree Krishna Hospital, Karamsad, Gujarat, India. 2. Professor, Department of Ophthalmology, Shree Krishna Hospital, Karamsad, Gujarat, India. 3. Assistant Professor, Department of Ophthalmology, Shree Krishna Hospital, Karamsad, Gujarat, India.

Correspondence Address :
Dhwani Satishbhai Mehta,
Bunglow No. 41, Shashwat Florence, Opposite Shree Krishna Hospital, Karamsad, Gujarat, India.
E-mail: dhwanimehta4655@gmail.com

Abstract

Introduction: Coronavirus Disease-2019 (COVID-19) can affect multiple system of body including eye. In eye, it can cause mild conjunctivitis, posterior segment involvement, neuro-sensory involvement and lethal opportunistic infection like mucormycosis. Associated co-morbidities, severity of COVID-19 infection and corticosteroids used in its management can affect ophthalmic involvement.

Aim: To determine the frequency and various types of ophthalmic manifestation of patients with COVID-19.

Materials and Methods: This prospective observational study was conducted on indoor patients of Shree Krishna Hospital, a rural, tertiary care hospital affiliated with Pramukh Swami Medical College, Karamsad, Gujarat, India, from 1st May 2021 to 1st January 2022. Second wave of COVID-19 was from 13th March 2021 to 19th June 2021. Patients’ demographic data, details of COVID-19 infection severity score, oxygen requirement, use of corticosteroids, history of various co-morbidities and stages of Rhino-Orbital-Cerebral Mucormycosis (ROCM) (if present) were noted. Bedside ophthalmic examination was done with torch light, fluorescent strip, cobalt blue light of direct ophthalmoscope and fundus examination with indirect ophthalmoscopy under institutional COVID-19 guidelines. Descriptive Statistics {Mean, (SD), Frequency, (%)} were used for analysis of the collected data.

Results: Out of 649 COVID-19 patients, 368 were male and 281 were female with mean age of 52.58 (±15.38) years. All over prevalence of ophthalmic manifestations was 9.86% (n=64 out of 649 patients). A total of 63 patients (9.71%) did not require any oxygen supplement, 352 patients (54.24%) required nasal prongs, 201 patients (30.97%) required non invasive ventilator support and 33 patients (5.08%) required mechanical ventilation. The 378 patients (58.24%) received corticosteroids in oral or intravenous form. A total of 325 patients (50.1%) had diabetes, 267 patients (41.1%) had hypertension, 29 patients (4.5%) had chronic kidney disease and 15 patients (2.3%) had thyroid disease. A total of 52 patients (8.01%) had conjunctivitis. Mean age of patients with conjunctivitis was 50.04 (±15.28) with male preponderance (n=30, 57.7%). Most common systemic presentation was fever (n=29, 55.8%). Patients with conjunctivitis had high D-dimer (>500 ng/mL) (n=42; 80.8%) and C-Reactive Protein (CRP) values (>3 mg/L) (n=39; 75%). A total of 144 patients (22.2%) were vaccinated with COVID-19 vaccine first dose while 10 patients (19.23%) out of 52 patients having conjunctivitis were vaccinated. Out of 649 patients, prevalence of ROCM was 1.85% (n=12) with mean age 58.58 years (±9.71 years) and male preponderance (n=8, 66.66%). Nine out of 12 patients had high blood sugar levels (mean level 340 mg/dL) at the time of admission. Out of 12, eight patients had received corticosteroids for management of COVID-19 infection. Six patients of ROCM (50%) did not require any oxygen support while two patient (16.7%) required nasal prongs for mean 7.50 days and four patient (33.3%) required non invasive ventilator support for mean 7.33 days (±2.5 days). One patient had stage 2C disease, one had stage 3B, five patients had stage 3C while five patients had stage 4C disease.

Conclusion: Ocular manifestations of COVID-19 range from conjunctivitis to ROCM. Conjunctivitis has mild and self-limited course while ROCM is sight threatening and life-threatening condition, if not treated appropriately.

Keywords

Coronavirus disease-2019, Conjunctivitis, Corticosteroids, Rhino-orbital-cerebral-mucormycosis

The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) was first identified in a few unusual pneumonia patients linked to the Wuhan seafood wholesale market in China in December 2019 (1). However, it soon grew out of China and the Coronavirus Disease 2019 (COVID-19) was declared a pandemic on 11th March 2020, and has been reported in 216 countries, areas or territories including India.

Symptoms of COVID-19 can range from fever, cough, loss of taste and smell, sore throat, headache, diarrhoea, skin rashes to more severe symptoms like chest pain and breathlessness (1). Apart from other systems, COVID-19 can affect patient’s eye in many ways (2). COVID-19 associated conjunctivitis can occur due to direct contact with a person having COVID (3),(4). Symptoms range from watering, foreign body sensation, red eye or can be asymptomatic. Signs of COVID-19 conjunctivitis includes congestion and follicular reaction. Disease usually resolves without any complication but epithelial keratitis, pseudo membrane or haemorrhagic conjunctivitis can occur. Tender lymphadenopathy can also occur (5).

Central retinal artery and vein occlusion are posterior segment findings which are associated with COVID-19 disease. Other retinal findings seen in COVID-19 are cotton wool spots and haemorrhages (6). Afferent visual pathway defect includes papillo-phlebitis, optic neuritis, papillo-oedema and posterior reversible encephalopathy (7). Miller-Fischer syndrome, cranial neuropathies, Adie’s pupil, ocular myasthenia gravis and nystagmus are possible efferent neuro-ophthalmic complications (8).

Mucormycosis is an opportunistic, potentially lethal angio-invasive fungal infection. They are of pulmonary, cutaneous, gastro-intestinal, disseminated or rhino-orbital cerebral type. Out of which rhino-orbital-cerebral type is most common (9). Prolonged use of corticosteroids, poorly controlled diabetes mellitus, lung diseases, malignancy and the immunocompromised state aggravates secondary infections (9),(10). Spores are inhaled through nasal cavity and spread to para-nasal sinuses via breach in mucosa. Through para-nasal sinuses they invade orbit through lamina paparycea, inferior orbital fissure, infratemporal fossa or orbital apex. Intracranial invasion occurs through superior orbital fissure, cribriform plate of ethmoid bone or perineural invasion (11). Hence, the present study was conducted with an aim to determine the frequency and various types of ophthalmic manifestation of patients with COVID-19.

Material and Methods

This prospective observational study was conducted on indoor patients of Shree Krishna Hospital, a rural, tertiary care hospital affiliated with Pramukh Swami Medical College, Karamsad, Gujarat, India, from 1st May 2021 to 1st January 2022. Second wave of COVID-19 was from 13th March 2021 to 19th June 2021. A total of 649 patients with COVID-19 were included in this study with no exclusion. Two out of 649 patients had unilateral proptosis, an ophthalmic manifestation and none had conjunctivitis at the time of admission as per medical records. After getting approval and clearance from the Institutional Ethics Committee (IEC/BU/130/FACULTY 15/171), the participants were enrolled in the study with their verbal consent.

Study Procedure

Patients’ demographic data (age and sex), details of COVID-19 infection severity score was determined on the basis of Computed Tomography (CT) severity score, oxygen requirement, use of corticosteroids, history of various co-morbidities and stages of ROCM (if present) were noted. Bedside gross anterior segment examination was done with torch light. Ocular surface examination was done with fluorescent strip, cobalt blue light of direct ophthalmoscope and fundus examination with indirect ophthalmoscopy under institutional COVID-19 guidelines.

COVID-19 infection severity was categorised as follows (12) on bases of CT severity score:

mild: <7
moderate: 7-18
severe: >18
Neutrophil to Lymphocyte ratio (N/L ratio) was categorised as follows (13):
<6: normal
6-9: mild elevation
9-18: moderate elevation
>18: severe elevation
In this study staging of ROCM was based on classification proposed by OPAI-IJO study (Table/Fig 1) (11).

Proven ROCM was defined as clinico-radiological features along with microbiological confirmation on direct microscopy and/or culture or histopathology with special stains or molecular diagnostics.

Alive with disease regression terminology is used when severity and spread of disease decreases after treatment. Alive with disease progression is used when severity and spread of disease increases after treatment. Stable residual disease terminology is used when after treatment disease remains same with no increase or decrease.(As per the terminology used in OPAI-IJO study) (11).

Statistical Analysis

As nature of the study was exploratory, descriptive statistics {Mean (SD), Frequency (n) and percentages (%)} were used to portray the profile, management and outcome of study population. Statistical Software (STATA (14.2)) was used for this study.

Results

All over prevalence of ophthalmic manifestations was 9.86% (n=64 out of 649 patients) (Table/Fig 2).

Amongst total patients, 144 patients (22.2%) were vaccinated with COVID-19 vaccine first dose while ten patients (19.23%) out of 52 patients having conjunctivitis were vaccinated with first dose of COVID-19 vaccine.

A total of 368 (56.70%) were male and 281 (43.30%) were female with mean age of 52.58 (±15.38) years (Table/Fig 3). Total 131 patients (20.18%) had mild COVID-19 infection severity score, 301 patients (46.38%) had moderate, and 217 patients (33.44%) had severe COVID-19 infection severity score. The 63 patients (9.71%) did not require any oxygen supplement, 352 patients (54.24%) required nasal prongs, 201 patients (30.97%) required non invasive ventilator support and 33 patients (5.08%) required mechanical ventilation. A total of 378 patients (58.24%) received corticosteroids in oral or intravenous form while 271 patients (41.76%) had not received corticosteroids. The 325 patients (50.1%) had diabetes, 267 patients (41.1%) had hypertension, 29 patients (4.5%) had chronic kidney disease and 15 patients (2.3%) had thyroid disease (Table/Fig 4).

Patients having conjunctivitis presented with systemic symptoms like fever (n=29, 55.8%), headache (n=22, 42.3%), cough (n=29, 55.8%), cold (n=29, 55.8%), fatigue (n=19, 36.5%) and breathlessness (n=22, 42.3%) (Table/Fig 5).

Most common ocular symptoms among patients with conjunctivitis was watering (n=10, 19.2%) followed by pain and foreign body sensation (n=9, 17.3%), itching (n=7, 13.5%) and blurring of vision (n=5, 9.6%). In rest of the patients, no symptoms were present (Table/Fig 5). Out of 52 patients having conjunctivitis, 42 patients (80.8%) with had D-dimer levels >500 ng/mL at the time of admission, while 39 patients (75%) had increased CRP levels (>3 mg/L) (Table/Fig 5).

Out of 52 patients of conjunctivitis, 3 patients (5.8%) had severe elevation (>18) in N/L ratio, 28 patients (53.8%) had moderate elevation (9-18), 15 patients (28.8%) had mild elevation (6-9) in N/L ratio. Rest six patients had normal N/L ratio. A total of 25 patients (48.1%) were known case of diabetes at the time of admission. A total of 15 patients (28.8%) had HbA1c value of >6.4% at the time of admission and 10 patients (19.2%) had value of pre-diabetic range (5.7%-6.4%). Other co-morbidities were hypertension (n=19, 36.5%) and chronic kidney disease (n=4, 7.7%).

ROCM Data

Out of 12 patients of mucormycosis, eight patients were male (66.7%) with mean age of 58.58 years (±9.71) (Table/Fig 3). Mean number of days from COVID-19 diagnosis to starting of ROCM symptoms are 12 (±2.6) (median: 10). Seven out of 12 patients had diabetes, 4 had hypertension and 1 had chronic kidney disease (Table/Fig 4).

Out of twelve patients of ROCM, 10 patients had cough and cold, nine patients had fever, five patients had breathlessness, four patients had fatigue and two patients had headache (Table/Fig 5). Blurring of vision was most common ocular symptom (n=10) followed by watering (n=9), pain and foreign body sensation (n=6) and itching (n=3) (Table/Fig 5). Out of 12 patients of ROCM, 11 patients had D-dimer levels >500 ng/mL at the time of admission while all 12 of them had increased CRP levels (>3 mg/L) and severe elevation (>18) of N/L ratio (Table/Fig 5).

Out of 12 patients, nine patients (75%) presented with orbital oedema followed by ptosis (n=7, 58.3%), orbital pain (n=2, 16.7%) and loss of vision (n=2, 16.7%). One patient had proptosis. Partial ophthalmoplegia involving III and VI nerve was seen in one patient (8.3%) and total ophthalmoplegia involving III, IV and VI nerve was seen in 9 patients (75%). One patient had trigeminal neve involvement and one patient had facial nerve involvement. Mean no. of days to develop ROCM symptoms from COVID-19 diagnosis were 12 (median: 10). One patient had stage 2C disease, one had stage 3B, five patients had stage 3C while five patients had stage 4C disease.

In present study, seven (58.3%) out of twelve patients of ROCM had pre-existing diabetes mellitus. On admission nine patients (75%) had high blood sugar level (mean HbA1c value 8.7%) out of which three were controlled by insulin and six patients had uncontrolled sugars with insulin. Mean HBA1c level of all 12 patients of ROCM was 10.75%.

Six patients of ROCM (50%) did not require any oxygen support while two patient (16.7%) required nasal prongs for mean 7.50 days (±3.54 days) and four patients (33.3%) required non invasive ventilator support for mean 7.33 days (±2.5 days). Maxillary sinus was most commonly involved sinus (n=6, 50%) as detected by Magnetic Resonance Imaging (MRI) scan followed by ethmoid sinus (n=4, 33.3%). One patient (8.3%) had pan sinus involvement. One patient (8.3%) had bilateral ethmoid, left-sided maxillary and left half of sphenoid sinus involvement.

Inferior orbital wall was most commonly involved (n=4, 33.3%) followed by medial orbital wall (n=3, 25%). Involvement of all four orbital walls was seen in one patient (8.3%). Temporal lobe involvement in MRI was seen in five patients (41.7%). One patient had skull base involvement (8.3%). One patient (8.3%) had pan sinusitis (stage 2C), one patient (8.3%) had diffuse orbital involvement (stage 3B), five patients (41.7%) had inferior orbital fissure and orbital apex involvement along with loss of vision in (stage 3C), and five patients (41.7%) had intracranial extension in the form of internal carotid artery invasion and skull base involvement (stage 4C). All patients had unilateral ocular involvement, in which right eye involvement was seen in five patients (41.66%) and left eye involvement in seven patients (58.34%). Four patients (33.3%) had no light perception in affected eye, two patients (16.7%) had only light perception and six patients (50%) had vision between (20/40 to 20/100). Optic nerve compression as confirmed by MRI study was the main cause of visual dysfunction in four patients with no light perception and two patients with light perception only.

In present study, one patient (8.3%) with diffuse orbital involvement was treated with FESS as primary management and showed disease regression. Three patients (25%) required FESS with exenteration, out of which two had Central Nervous System (CNS) involvement and one patient had orbital involvement. One patient with CNS involvement had stable disease while one was dead. Patient with orbital involvement who underwent FESS with exenteration had stable disease. Patient with CNS involvement who did not have any surgical intervention showed disease progression (n=2). No patient was given sinus irrigation or retrobulbar Amphotericin B. One patient was given step down therapy. Mean duration of hospital stay for ROCM treatment was 18.64 days (Median: 13 days).

After the due course of treatment one patient was alive with regression, five patients were alive with stable residual disease, two patients were alive with disease progression and four patients died. The authors had four patients in whom vision was salvaged (with final visual acuity between 20/40 to 20/100). Out of which two patients was given Amphotericin B as primary management, one patient was given FESS as primary management and one patient was given oral Posaconazole as primary treatment.

Discussion

In present study, out of 649 COVID-19 patients, the analysed overall prevalence of ophthalmic manifestations was 9.86% (n=64 out of 649 patients). Out of 649 patients, 52 patients (8.01%) had conjunctivitis and 12 patients (1.85%) had ROCM. In a study done by Sindhuja K et al., prevalence of conjunctivitis was 6.29% (8 out of 127 patients) (14). In a study done by Wu P et al., kumar KK et al., prevalence of conjunctivitis was 31.6% (12 out of 38 patients) and 0.72% (20 out of 2742) respectively (15),(16). In present study mean age of patients with conjunctivitis was 50.04 with male preponderance (n=30, 57.7%) while in a study done by Wu P et al., out of 12 patients of conjunctivitis, seven were males with median age of 67 (52 to 76) years (15).

In the present study, the most common systemic symptom in patients with conjunctivitis was fever (n=29, 55.8%). In a study done by Sindhuja K et al., cough (n=40, 31.49%) was the most common systemic symptom followed by the sore throat (n=10, 7.87%) and fever (n=6, 4.72%) in patients with conjunctivitis (14).

The most common ocular symptom was watering (n=10, 19.2%) followed by pain and foreign body sensation (n=9, 17.3%), itching (n=7, 13.5%) and blurring of vision (n=5, 9.6%). In a study done by Sindhuja K et al., out of eight patients of conjunctivitis, three patients (37.5%) had complaint of watering and out of these three patients one patient (12.5%) had complaint of itching (14).

In a study done in Germany by BostanciCeran B and Ozates S, 20 out of 93 patients (21.50%) having ocular involvement had significantly higher levels of N/L ratio (7.5±11.5) (17). In present study, out of 52 patients having conjunctivitis, 46 patients (88.46%) had higher levels of N/L ratio (>6) (Table/Fig 5).

In present study, seven (58.3%) out of 12 patients of ROCM had pre-existing diabetes mellitus. On admission nine patients (75%) had high blood sugar level (mean level 340 mg/dL) out of which three were controlled by insulin and six patients had uncontrolled sugars with insulin. Mean HBA1c level was 10.75%. Hyperglycaemia was aggravated in uncontrolled diabetics. Corticosteroids used in treatment of COVID-19 causes further hyperglycaemia and immunosuppression (18). Hyperglycaemia causes glycosylation of transferrin and ferritin and thus free iron level increases. All this led to acidic environment, which is favourable for fungal growth. Diabetes is independent risk factor for ROCM. In a prospective observational case series done by Sharma S et al., out of 23 patients of ROCM, 21 patients had diabetes and 12 were having uncontrolled blood sugars (19). In a study done by Patel A et al., the most common associated co-morbidity was diabetes mellitus among both ROCM and non ROCM groups (62.7%) (20).

In OPAI-IJO all India collaborative case study, the mean interval for onset of symptoms of ROCM from diagnosis of COVID-19 was found to be 14.5±10 days. ROCM can occur in post COVID-19 state (3 months after diagnosis of COVID). The mean age was 51.9 years (range: 12-88 years) with male preponderance (n=1993 out of 2826 patients) (11). In present study, mean number of days to develop ROCM symptoms from COVID-19 diagnosis were 12 (median: 10), the mean age was 58.58 years with male preponderance (n=8, 66.7%).

In present study, out of 12 patients of ROCM, most commonly observed ocular symptoms were orbital oedema followed by orbital pain and loss of vision. Most common ocular signs were orbital oedema followed by ptosis, facial discoloration and loss of vision. Out of twelve patients, one patient had partial ophthalmoplegia and nine patients had total ophthalmoplegia. Out of nine patients of total ophthalmoplegia, one patient had associated trigeminal nerve involvement and one patient had associated facial nerve involvement. In a study done by Roushdy T and Hamid E at Egypt, out of 4 patients of ROCM, all patients had ptosis,3 had total ophthalmoplegia and 2 had decreased visual acuity (21). Fouad YA et al., had studied 12 case of ROCM in which most common presenting signs were orbital-oedema and conjunctival chemosis (50%) followed by diminution of vision (41.7%), facial oedema (25%), nasal crusts (25%), total ophthalmoplegia (16.7%) and paralytic esotropia (8.3%) (18).

In present study, eight patients (66.6%) of ROCM had received corticosteroids, out of which one patient (8.3%) was given oral steroids for 21 days and seven (58.3%) patients were given intravenous steroids for mean 6.43 days. Intravenous methyl prednisolone was given to six (50%) patients and intravenous dexamethasone to one (8.3%) patient. Seven (58.3%) patients were given Remdesivir for 5.86 mean days. In a study done by Singh Y et al., eleven out of thirteen patients had received intravenous corticosteroids (22).

In present study, out of twelve patients, eleven patients (91.7%) were given liposomal Amphotericin B as primary treatment for mean 7.8 days (±5 days). Dose of Amphotericin B was calculated on the basis of weight of patient and state of renal involvement. One patient (8.3%) was given oral Posaconazole treatment for 5 days.

Limitation(s)

Due to single center study, the incidence of ocular manifestation may differ from multicenter study.

Conclusion

The COVID-19 infection can affect eye in various ways, from common eye disease like conjunctivitis to severe life threatening and sight threatening disease like ROCM. Though incidence of ROCM is less as compared to conjunctivitis, it has lethal mortality rate.

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DOI and Others

DOI: 10.7860/JCDR/2023/59956.17463

Date of Submission: Aug 30, 2022
Date of Peer Review: Oct 05, 2022
Date of Acceptance: Dec 06, 2022
Date of Publishing: Feb 01, 2023

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
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