TO THE EDITOR: In their article, Chiang et al 1 have updated the International Classification of Retinopathy of Prematurity (ICROP) to improve objectivity of finding, as well as to encompass clinical variations observed in regression or reactivation of retinopathy of prematurity (ROP), particularly after treatment with anti-vascular endothelial growth factor. The authors have subclassified zone II as anterior and posterior to identify the more serious disease in posterior zone II. However, the standard of care for the disease in both the zones is likely to be laser photocoagulation. To best of our knowledge, there is currently no study that has attempted to compare the outcomes of treatment between the anterior and posterior locations of zone II. In contrast, ROP in zone I, particularly posterior zone I, has been shown to have poor structural outcomes with laser monotherapy as opposed to a combination therapy with anti vascular endothelial growth factor and laser photocoagulation. 2,3 Kychenthal et al 4 have defined posterior zone I as a circular area centered on the optic nerve head, with a radius being the distance between the center of the optic disc and the fovea. However, this subdivision of zone II has not been used universally for documentation, sometimes referred to as the half zone. We suggest, similar to zone II, that zone I also be subdivided into anterior and posterior with reference to the fovea. This subdivision will not only ensure the objectivity of documentation of disease involving zone I, it will also have direct implications for deciding the appropriate treatment and prognosis based on currently available evidence.In the current classification, aggressive posterior ROP (APROP) has been replaced by aggressive ROP. For this change, the authors have cited a series of "fulminate ROP" by Shah et al. 2 The description of fulminate disease given by the authors in this article is very typical of APROP as described in ICROP 2. In their description, it is a disease that usually occurs within a definite zone, extending nasally 2 to 3 diameters from the disc margin and edge of the macula temporally. This area roughly corresponds with posterior zone I as described by Kychenthal et al. 4 The average gestational age and birth weight of infants in this series was more than typically described for fulminate ROP by others authors. Shah et al concluded that the zone I ROP occurred in babies with higher gestational ages and birth weights in India than in Western countries. We feel the word "posterior" in APROP can be retained because it is an integral part of disease description.

Purpose: Intraocular infection in patients with COVID-19 could be different in the presence of treatment with systemic corticosteroid and immunosuppressive agents. We describe the epidemiology and microbiological profile of intraocular infection in COVID-19 patients after their release from the hospital. Methods: We analyzed the clinical and microbiological data of laboratory-confirmed COVID-19 patients from April 2020 to January 2021 presenting with features of endogenous endophthalmitis within 12 weeks of their discharge from the hospital in two neighboring states in South India. The data included demography, systemic comorbidities, COVID-19 treatment details, time interval to visual symptoms, the microbiology of systemic and ocular findings, ophthalmic management, and outcomes. Results: The mean age of 24 patients (33 eyes) was 53.6 ± 13.5 (range: 5–72) years; 17 (70.83%) patients were male. Twenty-two (91.6%) patients had systemic comorbidities, and the median period of hospitalization for COVID-19 treatment was 14.5 ± 0.7 (range: 7–63) days. Infection was bilateral in nine patients. COVID-19 treatment included broad-spectrum systemic antibiotics (all), antiviral drugs (22, 91.66% of patients), systemic corticosteroid (21, 87.5% of patients), supplemental oxygen (18, 75% of patients), low molecular weight heparin (17, 70.8% of patients), admission in intensive care units (16, 66.6% of patients), and interleukin-6 inhibitor (tocilizumab) (14, 58.3% of patients). Five (20.8%) patients died of COVID-19-related complications during treatment for endophthalmitis; one eye progressed to pan ophthalmitis and orbital cellulitis; eight eyes regained vision >20/400. Fourteen of 19 (73.7%) vitreous biopsies were microbiologically positive (culture, PCR, and microscopy), and the majority (11 patients, 78.5%) were fungi. Conclusion: Intraocular infection in COVID-19 patients is predominantly caused by fungi. We suggest a routine eye examination be included as a standard of care of COVID-19.

Purpose: To describe disease manifestations and outcomes of ocular syphilis in Asian Indian population. Methods: Retrospective analysis of patients diagnosed with ocular syphilis at a tertiary referral center in India. Demographics, history, extraocular and ocular manifestations, ocular and systemic investigations, treatment and visual acuity outcomes were noted. All patients were diagnosed after necessary laboratory investigations including HIV ELISA (Human immunodeficiency virus, enzyme-linked immunosorbent assay), VDRL (venereal disease research laboratory), and TPHA (treponema pallidum hemagglutination). Results: Totally, 20 patients with mean age at presentation 38.25 ± 9.76 were analyzed. 9/20 patients had bilateral involvement. 8/20 had concurrent HIV at presentation with an average CD4 counts of 592.25 ± 411.34 cells/microliter. The mean duration of symptoms at time of presentation was 15.45 ± 35.15 weeks. VDRL test was reactive in 45% (9/20) patients whereas, all patients had a reactive TPHA test. Clinical manifestations included outer retinal placoid chorioretinitis lesions (8/20, 40%), followed by retinitis mimicking acute retinal necrosis as the second most common phenotype (4/20, 20%). Other presenting manifestations noted were panuveitis, miliary retinitis lesions, retinal vasculitis, intermediate uveitis, and anterior uveitis. The clinical phenotypes in immunocompromised included panuveitis, acute retinal necrosis and isolated anterior uveitis. Mean follow up duration was 6.32 ± 6.15 months. An improvement in mean best corrected visual acuity (BCVA) of (0.63 LogMAR, approximately 6 Snellen lines, P < 0.02) was noted at last follow-up. Conclusion: Phenotypic manifestations of ocular syphilis are varied. Non-treponemal tests like VDRL may be unreliable when compared with treponemal tests in diagnosing ocular syphilis. Syphilitic uveitis is considered equivalent to neurosyphilis and is treated similar to neurosyphilis.