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

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Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
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Dr Mohan Z Mani,
Professor & Head,
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 : June | Volume : 17 | Issue : 6 | Page : NC13 - NC16 Full Version

Clinical Features of Post Fever Retinitis and Visual Outcomes with Oral Corticosteroids: A Retrospective Study


Published: June 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/60128.18037
Sanjanashree S Patil, Vishalakshi, Charushila V Gejapati

1. Junior Resident, Department of Ophthalmology, SDM College of Medical Sciences and Hospital, Shri Dharmasthala Manjunatheshwara University, Dharwad, Karnataka, India. 2. Assistant Professor, Department of Ophthalmology, SDM College of Medical Sciences and Hospital, Shri Dharmasthala Manjunatheshwara University, Dharwad, Karnataka, India. 3. Associate Professor, Department of Ophthalmology, SDM College of Medical Sciences and Hospital, Shri Dharmasthala Manjunatheshwara University, Dharwad, Karnataka, India.

Correspondence Address :
Dr. Vishalakshi,
Assistant Professor, Department of Ophthalmology, SDM College of Medical Sciences and Hospital, Shri Dharmasthala Manjunatheshwara University, Dharwad-580009, Karnataka, India.
E-mail: drvishalakshi@gmail.com

Abstract

Introduction: Post Fever Retinitis (PFR) is an infectious or parainfectious uveitis presenting with visual impairment after a fever episode. The condition can cause potential visual impairment in PFR patients. There is no national guideline for treatment of PFR. Hence, there is a need to study the clinical features and visual outcomes with the use of corticosteroid therapy.

Aim: To describe the clinical features of patients presenting with PFR and visual outcome with the oral corticosteroid therapy.

Materials and Methods: This retrospective study conducted in the Outpatient Department (OPD) of Ophthalmology at SDM College of Medical Sciences and Hospital, Dharwad, Karnataka, India. The duration of the study was 35 months, from January 2019 to December 2021. A total of 23 eyes of 13 patients treated with oral corticosteroids were included. Data collected included patients’ demographic details including name, age, sex, hospital identification number, duration of vision loss, detailed ophthalmic examination findings, including visual acuity testing with Snellen’s chart, slit lamp examination findings and fundus examination findings, including detailed fundus drawings, Optical Coherence Tomogram (OCT) and fundus photographs. Visual Acuity (VA) at the time of presentation and after steroid therapy were recorded. Data was entered in microsoft excel spreadsheet and descriptive analysis was done.

Results: Age of the study participants ranged from 15 years to 52 years with an average of 29.6 years. A total of 23 eyes of 13 patients were included in the present study. At the time of presentation, two eyes had visual acuity better than 6/12 on Snellen’s chart. Five eyes had mild vision impairment, five eyes had moderate vision impairment and eleven eyes had vision <3/60, according to the visual impairment classification of World Health Organisation (WHO). Macular oedema was the other most common finding seen in 12 (52.17%) eyes. All the patients showed beginning of resolution of retinitis by 2-3 weeks after starting oral corticosteroids. A total of 23 eyes, 8 (34.7%) eyes recovered vision >6/12, out of which 6 (26.08%) eyes recovered with 6/6 vision.

Conclusion: PFR affects predominantly young immunocomp-etent individuals. Treatment outcomes with oral steroids is found to be satisfactory.

Keywords

Macular oedema, Oral steroid therapy, Parainfectious uveitis, Visual acuity

The PFR is an infectious or para infectious uveitis entity caused by several organisms, presenting as focal or multifocal retinitis. It is commonly seen in tropical countries and can be caused due to several viruses or bacterial agents, usually presenting days to weeks after the initial febrile episode (1). The exact aetiopathogenesis of this condition is unclear. Most of the time the patient is afebrile and systemic features are absent at the time of presentation to the ophthalmologist. It may not be possible to pin point an underlying aetiological agent in all the cases. However, it is prudent to rule out the treatable bacterial causes which might have caused the PFR episode. Knowledge of the recent outbreaks or endemic infections in the region may point to a probable aetiology. There is no set guideline for treatment of cases of PFR. Ophthalmologists generally treat these cases with high dose corticosteroids with or without antibiotics (2). There are not many studies about PFR from Northern Karnataka region, and only case reports having been published so far. The present study describes the clinical features of cases of PFR presenting to Ophthalmology OPD of SDM College of Medical Sciences and Hospital, Dharwad, which is a tertiary care referral centre in North Karnataka. The present study also describes the visual outcomes after treatment with oral corticosteroids.

Material and Methods

This retrospective observational study was conducted in the OPD of Ophthalmology at SDM College of Medical Sciences and Hospital, Dharwad, Karnataka, India. The duration of the study was 35 months, from January 2019 to December 2021. The Institutional Ethics Committee clearance was obtained and the study adhered to the tenets of declaration of Helsinki (letter no: ECR/950/Inst/KA/2017/RR-21) and informed consent was obtained from the patients prior to the study.

Inclusion criteria: All the patients diagnosed clinically with retinitis with a history of fever in the preceding four weeks during the study period were included in the study.

Exclusion criteria: Patients with specific retinitis entities such as, toxoplasma retinitis and Cytomegalovirus retinitis which require specific therapy were excluded in the study.

Study Procedure

Data collected included patients demographic details including name, age, sex, hospital identification number, duration of vision loss, detailed ophthalmic examination findings including visual acuity testing with Snellen’s chart, slit lamp examination findings and fundus examination findings including detailed fundus drawings, OCT and fundus photographs. Basic investigations included complete haemogram, erythrocyte sedimentation rate, blood pressure, random blood sugar levels, Human Immunodeficiency Virus (HIV) Enzyme-linked Immunosorbent Assay (ELISA), Hepatitis B Surface Antigen (HBsAg), mantoux test, and chest X-ray. Other investigations were carried out as necessary like widal test, chikungunya IgG/IgM, dengue IgG/IgM, malaria parasite and Weil-Felix test. History of exposure to pets including any scratches/bites by cats was elicited. All the patients were treated with oral prednisolone (tablet omnacortil, macleods pharmaceuticals Ltd.,) 1 mg/kg body weight which was tapered over a period of 6-8 weeks. The ocular examination findings at follow-up visits at one week and six weeks were noted down and the visual acuity at six weeks follow-up was considered for measuring final visual outcomes. The visual impairment was classified as mild (VA of 6/12 to 6/18), moderate (VA of 6/18 to 6/60), severe (VA 6/60 to 3/60) and blindness-(VA <3/60) as per WHO classification (3). Improvement in VA and reduction in size of retinitis lesions were considered as signs of improvement.

Statistical Analysis

The data collected were entered into Microsoft excel spreadsheet. Descriptive statistics were applied to the data. Descriptive statistics of the explanatory and outcome variables were calculated by mean and range. Frequency and proportions for qualitative variables were calculated where applicable.

Results

During the study period, a total of 27 eyes of 15 patients were examined and diagnosed as PFR. Out of these, two patients with bilateral disease did not come for follow-up after the initial visit and were excluded from the study. A total of 23 eyes of 13 patients were included in the present study. Ten patients had bilateral disease and three had unilateral eye involvement. A total of 13 subjects, 7 (53.8%) were males and 6 (46.1%) were females. Age of the subjects ranged from 15 years to 52 years with an average of 29.6 years. All the patients presented with diminution of vision in the affected eye. All had a history of fever in the preceding four weeks. The duration between onset of fever and vision impairment ranged from two days to four weeks, with an average of two weeks. None were febrile at the time of presentation to ophthalmic OPD. None of the patients were on any oral medications for the febrile episode at the time of diagnosis of PFR.

At the time of presentation, 2 (8.6%) eyes had visual acuity better than 6/12 on Snellen’s chart, 5 (21.7%) had mild vision impairment, 5 (21.7%) had moderate vision impairment and 11 (47.8%) had vision <3/60 (3). Low grade anterior chamber reaction of 1+ was present in four eyes. Relative afferent pupillary defect was present in two eyes of two patients. On fundus examination, vitritis was present in nine eyes. None had dense vitritis preventing retinal examination. Retinal examination showed yellow-white cotton wool spot like retinal lesions with fuzzy borders suggestive of retinitis, either focal or multifocal, in all the eyes. The lesions were noted in the posterior pole and around the arcade vessels. None of the eyes showed lesions in the periphery of the retina. Other retinal findings included disc hyperaemia (four eyes), disc oedema (two eyes), macular oedema (12 eyes), macular star/fan (3 eyes), retinal vascular sheathing (4 eyes), retinal haemorrhages (14 eyes) and involvement of foveal area by the retinitis patch (5 eyes). Macular oedema was one of the most common finding seen in 12 (52.17%) eyes. The lesions were noted to be predominantly in the posterior pole. (Table/Fig 1)a,b shows fundus photographs of a patient with bilateral retinitis lesions in the posterior pole.

A total of 13 patients, underlying aetiology could be determined in only 5 (38.46%) patients. Two had a positive Weil-Felix test at the time of fever episode, one had a positive Widal test and two patients were positive for IgM chikungunya virus. Two patients had been suspected to have rickettsial infection at the time of the febrile episode but were Weil-Felix test negative, and had been treated with oral doxycycline (tab DOXT-SL, Dr. Reddy’s Laboratories Ltd.,) for two weeks by the physician. Immune Fluorescence Assay (IFA) was not done in all suspected rickettsia patients due to non availability. All the patients were Coronavirus Disease-2019 (COVID-19) Real Time-Polymerase Chain Reaction (RT-PCR) negative at the time of diagnosis of retinitis. Rest of the subjects did not test positive for any of the tests conducted. None of the patients had exposure to pets or history of cat bite/scratch. Erythrocyte Sedimentation Rate (ESR) ranged from 4 mm/hr to 80 mm/hr with an average 31.4 mm/hr. All the patients were treated with oral prednisolone (tablet omnacortil, macleods Pharmaceuticals Ltd.,) 1 mg/kg body weight which was tapered over a period of 6-8 weeks. A physician clearance was taken for all patients before starting on oral corticosteroids. Four patients received additional oral doxycycline 100 mg twice a day for four weeks. Doxycycline was added for patients with proven or suspected rickettsial infection. The patient who had a positive Widal test was already treated with oral ciprofloxacin 500 mg twice a day for two weeks by the physician. All the patients showed beginning of resolution of retinitis by 2-3 weeks after starting oral corticosteroids. (Table/Fig 1)c,d shows the beginning of resolution in a patient with bilateral involvement. (Table/Fig 2)a,b shows the fundus photograph of left eye of a patient with unilateral retinitis before and after initiation of treatment. Out of the 23 eyes, 8 (34.7%) eyes recovered vision >6/12 with 6 (26.08%) eyes having 6/6 vision. Three eyes had mild vision impairment with VA of 6/12 to 6/18, 7 (30.4%) eyes had moderate vision impairment of 6/18 to 6/60 and three eyes had severe visual impairment of 6/60 to 3/60. 2 (8.6%) eyes had vision worse than 3/60. Comparison of visual acuity at the time of presentation and at six weeks is shown in (Table/Fig 3).

Discussion

The PFR has been reported from different regions. A detailed ocular examination of patients presenting with visual disturbance after an episode of fever helps in identifying these cases. In the present study, 10 patients with bilateral disease and three with unilateral involvement have been described. PFR can present with either unilateral or bilateral involvement. The average age of the study participants was 29.6 years with a age range of 15 years to 52 years. Other studies have also described incidence of PFR in 15young and middle-aged patients (4),(5). Thus, PFR is seen more in younger adults when compared to the elderly subjects, probably due to a stronger immune system in the younger population. The average duration between fever and onset of defective vision was two weeks in the present study. None of the patients were febrile at the time of ocular examination. The delay in ocular findings and absence of fever favour an immunological mechanism for development of PFR. Another author has also hypothesised a similar theory (6). All the patients in the present study, presented with defective vision and showed multifocal areas of retinitis.

Macular oedema, seen in 52% of the cases, was the most common finding in the present study. Sundar DM et al., have reported clinical features, OCT findings and treatment outcomes in 19 eyes of 13 patients with PFR and found 69% patients had macular oedema (4). They reported complete or incomplete macular star, seen in 95% of their cases as the most common finding in association with retinitis. In the present study, authors noted macular star or fan in 3 eyes (13%) of the subjects. The retinitis lesions were predominantly in the posterior pole with involvement of foveal area in five eyes. None of the study participants had involvement of retinal periphery by the retinitis lesions. Shenoy P et al., have reported a similar posterior pole and peripapillary involvement in their case study (7). Khochtali S et al., in a retrospective study of PFR, reported involvement of retinal periphery in 75% of their cases with acute multifocal retinitis (8). They also observed the exudative retinal detachment in 10% of their subjects. Vascular sheathing was noted in four eyes in the present study. Sheathing occurs due to an inflammation of the retinal vessels, and may cause minor or major vein occlusions in the retina. Vascular occlusions and immune complex mediated occlusive vasculopathy has been reported in cases with dengue retinitis (9). Other features of dengue retinitis are foveolitis, macular oedema and disc hyperaemia (10).

In the present study, four eyes had disc hyperemia of which two had associated disc oedema. The study participants were negative for dengue serology. West Nile Virus (WNV) infection can cause disc oedema and neuroretinitis (11). However, the typical linear pattern of chorioretinitis patches described in WNV retinitis was not seen in any of the study patients. Underlying aetiology could be determined in only four patients. Confirmatory test of Immunufluoroscence Assay (IFA) for rickettsia infection could not be performed due to lack of availability. Patients with chikungunya infection, can present with retinitis, neuroretinitis and optic neuritis (12). The patients who tested positive for IgM chikungunya, were afebrile at the time of presentation to us and had only ocular signs of multifocal retinitis. Recurrent chikungunya retinitis has been reported after steroid taper by Salceanu SO and Raman V (13). In the present study, such recurrence was unnoticed. All the patients tested COVID-19 RT-PCR negative at the time of diagnosis of PFR. Mahendradas P et al., have reported a case of bilateral PFR with vascular occlusions presenting three weeks after the febrile illness due to Severe Acute Respiratory Syndrome (SARS)-CoV-19 infection (14). The retinitis in their case improved with oral steroids, doxycycline and anticoagulants. All the patients in the present study had received oral prednisolone 1 mg/kg body weight, which was tapered over 6-8 weeks depending on the response. All the patients showed signs of improvement with oral corticosteroids with 34.7% showing significant visual improvement. Other studies have reported similar improvement on treatment with corticosteroids in cases of PFR (1),(15). High dose methyl prednisolone has also been considered for treatment (16). Shenoy P et al., reported the findings in a large cohort of patients with PFR and their response to steroids (7). They found nearly two-third patients improved within four weeks of starting oral steroids. In their study, they did not observe any additional benefits of intravenous steroids. Vishwanath S et al., also have reported resolution of retinitis in all cases following treatment with oral steroids (1). Kawali A et al., compared the treatment outcomes in epidemic retinitis treated with or without steroids and found that, epidemic retinitis with macular oedema could be well managed without corticosteroids (17).

Chawla R et al., have reported a case of rickettsial retinitis which worsened with initial monotherapy with steroids and showed improvement after the initiation of oral doxycycline (18). Other authors also have advocated the use of oral doxycycline and intravitreal injection of bevacizumab for treatment of these cases (4). Without any other proven treatment modalities available for specific treatment of PFR, corticosteroids remain the therapy of choice. In the present study, 2 eyes (8.6%) had poor vision at the end of six weeks. These were the cases with involvement of the foveal area by the retinitis lesion. These also had poor visual acuity at the time of presentation. Shenoy P et al., found larger size of the lesion, presence of haemorrhages and disc involvement to be associated with late response to treatment (7). Biswal S et al., reported the predictors of visual outcome in post fever retinitis. They found increase in central macular thickness, subretinal fluid height, presence of Disorganisation of Retinal Inner Layers (DRIL), subfoveal deposits and ellipsoid zone loss to be negatively correlated with final visual acuity (19).

In the present study, patients showed improvement in retinitis with oral corticosteroids irrespective of the underlying aetiology. Patients with suspected or proven rickettsial infection needed additional treatment with oral doxycycline. Visual outcomes depended on the involvement of foveal area by the retinitis lesions.

Limitation(s)

Limitations of the present study were its retrospective nature, possibility of recall bias regarding details during fever episode, lack of long term follow-up and non availability of OCT images and fundus fluorescein angiograms in all patients. Well-designed prospective studies with inclusion of large number of patients will help overcome the existing limitations. A thorough systemic work-up can shed more light on the underlying aetiology in these cases. Fundus fluorescein angiogram can be helpful to know the macular perfusion and help to prognosticate the visual outcomes in these patients.

Conclusion

The PFR is predominantly seen in young population in the Northern Karnataka region. Underlying aetiology may not be confirmed in all the cases. Patients with visual loss may have unilateral or bilateral involvement by focal or multifocal retinitis with macular oedema being a common finding. Oral corticosteroid therapy is associated with improvement and resolution of retinitis. Foveal involvement is associated with poor visual outcomes. It is therefore, necessary to watch out for visual impairment in cases with bacterial or viral febrile episode. Therapy with oral corticosteroids is beneficial in visual recovery.

Acknowledgement

The authors would like to thank for the academic support and encouragement provided by Dr. Anupama Desai, Professor and Head of the Department and Dr. Shankargouda Patil, Professor, Department of Ophthalmology, SDM College of Medical Sciences and Hospital, Shri Dharmasthala Manjunatheshwara University, Dharwad, Karnataka, India.

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DOI and Others

DOI: 10.7860/JCDR/2023/60128.18037

Date of Submission: Sep 08, 2022
Date of Peer Review: Nov 19, 2022
Date of Acceptance: Jan 24, 2023
Date of Publishing: Jun 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. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Sep 10, 2022
• Manual Googling: Dec 20, 2022
• iThenticate Software: Jan 18, 2023 (10%)

ETYMOLOGY: Author Origin

Emendations: 6

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