Curated article summaries

1. HERPES ZOSTER OPHTHALMICUS RECURRENCE: RISK FACTORS AND LONG-TERM CLINICAL OUTCOMES Scott DA, Liu K, Danesh-Meyer HV, Niederer RL. Herpes zoster ophthalmicus recurrence: Risk factors and long-term clinical outcomes. Am J Ophthalmol 2024;268:1-9. SUMMARY Herpes zoster is caused by the reactivation of the Varicella zoster virus in patients who have been infected with chickenpox. Herpes zoster ophthalmicus (HZO) occurs due to the reactivation of the virus within the trigeminal ganglion, affecting the ophthalmic division of the nerve. Approximately 20% of herpes zoster patients have HZO. Complications include postherpetic neuralgia and vision-threatening conditions such as corneal scarring, perforation, secondary glaucoma, and uveitis. There is a 25% increased risk of HZO among immunocompromised patients. Recurrence of HZO is a nightmare for both the patient and clinician. It is presumed that the reactivation of the virus occurs due to an immune-mediated response to the VZV virus within the ocular tissues. This is a retrospective cohort study of 869 patients with HZO from Auckland, New Zealand, who were identified with the disease between 2006 to 2016 and were followed up until 2019. Out of these, 551 recurrences were noted. They observed that uveitis was the most common form of recurrence. The important ocular risk factors identified for recurrence were high baseline intraocular pressure/ocular hypertension, uveitis, and chronicity of ocular disease. Cataract surgery, prolonged usage of topical steroids, and systemic immunosuppression were also found to trigger recurrences. Interestingly, the timing of steroid cessation also contributed to the relapse of HZO. They also found a significant association between the number of recurrences and degree of vision loss in the patients. Moderate to severe vision loss was reported in patients who had more than one recurrence. WHY THIS ARTICLE? This study is the largest in the literature to evaluate the risk factors and long-term clinical outcomes of patients with HZO recurrence. An in-depth knowledge and prompt recognition of these risk factors will go a long way in reducing the rates of HZO recurrence. Judicious use of topical steroids and close monitoring in high-risk individuals will help decrease visual morbidity and improve their quality of life. 2. INCREASED SERUM FERRITIN IS ASSOCIATED WITH SEVERITY OF ORBITAL DISEASE IN COVID-19–ASSOCIATED RHINO-ORBITO-CEREBRAL MUCORMYCOSIS: A QUANTITATIVE ANALYSIS Tanwar S, Mishra N, Sharma P, Kaur A. Increased serum ferritin is associated with severity of orbital disease in covid-19–associated rhino-orbito-cerebral mucormycosis: A quantitative analysis. Indian J Ophthalmol 2024;73:223-7. SUMMARY Mucormycosis is a potentially devastating fungal infection that has been increasingly reported during the Covid and post-Covid times. The most common presentation is rhino-orbito-cerebral mucormycosis (ROCM). There was an unprecedented rise in incidence in India, especially during the the second wave of Covid. Approximately 81% of Covid-associated ROCM cases were reported from India. Its rapid progression and high mortality rate caused significant concern among healthcare professionals worldwide. The important risk factors identified are Covid -19 infection, uncontrolled diabetes mellitus, iron overload, neutropenia, the use of steroids/immunomodulators, prolonged oxygen therapy, and mechanical ventilation. Poor glycemic control is the most important risk factor, as the fungus thrives in a hyperglycemic environment. High blood sugar levels also cause impaired sequestration of iron. As iron sequestration is one of the major host defense mechanisms against fungi, this impairment leads to a further worsening of the condition. Raised serum ferritin is observed when iron levels are increased. This study was a cross-sectional tertiary care study conducted to assess the role of serum ferritin in Covid-19 associated ROCM cases as a biochemical marker of the severity of orbital disease. It was conducted at King George Medical University, Lucknow, Uttar Pradesh, from May 2021 to June 2021. A total of 100 patients with signs of ROCM were included in this study. The following biochemical parameters were assessed in all patients: serum ferritin, fasting blood sugar, postprandial blood sugar, C-reactive protein, D-dimer, and interleukin-6. All these parameters were elevated in the patients analyzed in this study, but only serum ferritin showed a statistically significant increase and positive correlation with the severity of orbital involvement. Multiple regression analysis confirmed that serum ferritin could independently contribute to the severity of orbital disease. WHY THIS ARTICLE? Orbital mucormycosis is a dreaded complication of Covid-19 infection. This study reveals that, apart from uncontrolled blood sugar levels, serum ferritin also plays a significant role in the pathogenesis and mortality associated with Covid-19–associated ROCM.