COVID-19 and Eye: A Review of Ophthalmic Manifestations of COVID-19

The pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has had health implications of unprecedented magnitude. The infection can range from asymptomatic, mild to life threatening respiratory distress. It can affect almost every organ of the body. Ophthalmologists world over are reporting various manifestations of the infection in the eye. This review was undertaken to help ophthalmologists recognize the possible manifestations and the stage of the viral disease when they commonly appear. Literature search was performed for the publications on ophthalmic manifestations of coronavirus disease-19 (COVID-19) between January 1, 2020 and January 31, 2021. 46 case reports, 8 case series, 11 cross sectional/cohort observational studies, 5 prospective interventional studies, 3 animal models/autopsy studies and 6 reviews/meta-analysis were included. Conjunctivitis is the most common manifestation and can develop at any stage of the disease. Direct effect due to virus, immune mediated tissue damage, activation of the coagulation cascade and prothrombotic state induced by the viral infection, the associated comorbidities and drugs used in the management are responsible for the findings in the eye. The viral ribonucleic acid (RNA) has been isolated from ocular tissues but the role of eye as a route for infection is yet to be substantiated. Ophthalmic manifestations may be the presenting feature of COVID-19 infection or they may develop several weeks after recovery. Ophthalmologists should be aware of the possible associations of ocular diseases with SARS-CoV-2 in order to ask relevant history, look for specific signs, advise appropriate tests and thereby mitigate the spread of infection as well as diagnose and initiate early treatment for life and vision threatening complications.     

Knowledge,attitude, and practice of ophthalmic manifestations in COVID-19 patients at a tertiary care center

Purpose:Since the start of the COVID-19 pandemic, various manifestations have been reported, including ophthalmic symptoms, especially with the different mutations and variants that have occurred over the last few years. In view of this, our study was conducted to gauge the knowledge, attitude, and practices of patients toward the ophthalmic manifestations of COVID-19.Methods:This was a hospital-based, cross-sectional, observational study. Patients who had tested positive for COVID-19 were asked to answer a detailed questionnaire about their knowledge of COVID-19 ophthalmic symptoms, their experience with the symptoms, and their attitude and practice toward the same. The data collected was analyzed using Microsoft Excel, and the Chi-squared test was used to determine significant differences in the results among different demographic profiles.Results:Our study found that 82 (39%) of the 210 participants were aware that COVID-19 could present with symptoms in the eyes. A total of 47 participants had experienced eye symptoms of COVID-19. Among them, only 15 (31.91%) consulted and received treatment from an ophthalmologist or general physician for the same. Most of them (59.57%) did not seek any treatment, and 8.5% self-medicated or used non-allopathic forms of medicine. The most common symptom was redness of the eyes, reported by 57.44% of those who had eye symptoms.Conclusion:Most people were unaware of ocular manifestations of COVID-19 and most of those who were aware were medical professionals. Amongst those who developed symptoms, only a minority sought medical treatment.     

Superior Ophthalmic Vein Thrombosis as an Initial Manifestation of Antiphospholipid Syndrome

ABSTRACT

Purpose: To report an uncommon case of superior ophthalmic vein occlusion secondary to antiphospholipid syndrome.

Method: Interventional case report.

Result: A 41 year old man who presented with acute proptosis and ophthalmoplegia who was initially treated for orbital cellulitis. His CT scan showed changes consistent of that a superior ophthalmic vein thrombosis. He was managed with high dose intravenous steroid and commenced on anticoagulant therapy. He was subsequently diagnosed with antiphospholipid syndrome.

Conclusion: Although superior ophthalmic vein occlusion is rare it is an important differential. This is the first reported case secondary to antiphospholipid syndrome.     

Ophthalmic manifestations of acute and chronic leukemias presenting to a tertiary care center in India

Context:Screening for ocular manifestations of leukemia, although not a routine practice, is important as they may antedate systemic disease or form an isolated focus of its relapse.Aims:This study evaluates the spectrum of ocular manifestations in acute and chronic leukemias presenting to a tertiary care center in India.Results:The study subjects (n = 96) comprised 61 males and 35 females whose age ranged from 18 months to 91 years (mean = 39.73, ±22.1). There were 79 adults and 17 children, 53 new and 43 existing patients, 68 acute and 28 chronic, 61 myeloid and 35 lymphoid patients. Ocular lesions were found in 42 patients (43.8%). The ocular manifestations of leukemia were significantly (P = 0.01467) more frequent in acute 35/68 (51.9%) than chronic 7/28 (25%) leukemias. Primary or direct leukemic infiltration was seen in 8 (8.3%) subjects while secondary or indirect involvement due to anemia, thrombocytopenia, hyperviscosity, total body irradiation, and immunosuppression were seen in 42 (43.8%) subjects. Ocular changes were present in 37/79 (46.8%) adults and 5/17 (29.4%) children (P = 0.09460). Twenty-eight males (28/61) 45.9% and 14/35 (40%) females had ocular manifestations (P = 0.2874). The ocular manifestations were significantly (P = 0.01158) more frequent in myeloid leukemias 32/61 (52.9%) than lymphoid leukemias 10/35 (28.6%).Conclusions:Leukemic ophthalmic lesions were found in 42/96 (43.8%) patients. Ocular involvement is more often seen in adults, acute and myeloid leukemias. All the primary leukemic manifestations were seen in males. A periodic ophthalmic examination should be mandatory for all leukemic patients, as ocular changes are often picked up in asymptomatic patients.AimTo study the spectrum of ocular manifestations in acute and chronic leukemias presenting to a tertiary center in India.     

新型冠状病毒肺炎的眼部表现

新型冠状病毒肺炎(coronavirus disease 2019,COVID-19,新冠肺炎)是由新型冠状病毒(novel coronavirus,SARS-CoV-2,新冠病毒)引起的一种具有高度传染性的疾病,目前在世界各地广泛流行,并引起全球性恐慌。研究表明,新冠病毒可以通过眼部黏膜传播,因此眼科医务人员更容易受到感染。新冠肺炎患者眼部表现主要累及结膜、角膜、巩膜、前房、瞳孔、视网膜、视神经和视皮层、眼外肌及其颅神经支配、眼眶和泪器系统等。病毒性结膜炎是新冠肺炎患者最常见的眼部表现。新冠肺炎流行期间,为了眼科医务人员免受感染,安全地开展临床工作,本文依据近年来相关文献报道总结了新冠肺炎的眼部表现,主要包括流行病学、病理生理、临床表现等方面。     

Subconjunctival Dirofilariasis presenting as orbital cellulitis

Background:Dirofilariasis is an emerging zoonosis in India. Most of the cases from India have been reported from the states of Kerala, coastal Karnataka and Maharashtra, and a few from the North India, Orissa and Assam. Dogs, cats, foxes and other wild animals are definitive hosts for dirofilaria. Human ocular parasitosis is prevalent in geographical areas where environmental factors and poor sanitary conditions favor parasitism between humans and animals. However, in recent years, migrating population have facilitated the spread of certain parasitic diseases from endemic to non-endemic areas. We report a case of subconjunctival dirofilariasis in a 91-year-old man, who presented with features of orbital cellulitis. An intact live worm, measuring 13.5 cm, was extracted from the subconjunctival space, following which there was prompt resolution of symptoms.Purpose:Given the increase in the frequency of dirofilariasis in humans in recent years, medical practitioners should bear in mind the possibility of ocular dirofilariasis when a patient presents with an ocular or orbital inflammatory lesion.Synopsis:This video illustrates various presentations of ocular dirofilaria and surgical extraction of a live worm from the subconjunctival space.Highlights:Lifecycle and human ocular manifestations of dirofilaria ared elucidated. Rare presentation of subconjunctival dirofilariasis as orbital cellulitis and its resolution following removal of the live worm has been demonstrated.Video link: https://youtu.be/Nj8unz0S85M     

Wilson 病的眼部表现

目的 探讨Wilson病(WD)眼部表现的情况.方法 采用非随机回顾性系列病例研究.对2002年1月至2006年4月在中山大学附属第一医院住院的52例Wilson病患者的家族史、临床表现及实验室检查等临床资料进行分析,按照临床表现将其分为无症状筛查组、仅有肝脏病变组、仅有神经病变组及混合组(兼有肝脏和神经病变)4组.结果 52例患者中男性32例,女性20例,比例为1.6∶1.0.年龄4～53岁,平均(20±1)岁,其中41例(78.8%)在10～30岁之间.14例(26.9%)有家族史,3例(5.8%)有可疑家族史.无症状筛查组2例(2/52,3.8%),其中1例(1/2)K-F环阳性;12例(12/52,23.1%)仅有肝脏病变,其中7例(7/52,13.5%)K-F环阳性;11例(11/52,21.2%)仅有神经病变患者全部K-F环阳性(11/11,100%);27例(27/52,51.9%)兼有肝脏和神经病变,其中26例(26/27,96.3%)K-F环阳性.共45例(45/52,86.5%)K-F环阳性,7例(13.5%)无K-F环.1例(1.9%)有"向日葵"样白内障,1例(1.9%)有眼球震颤.51例(98.1%)铜蓝蛋白降低,51例(98.1%)24 h尿铜排泄量大于正常.结论 K-F环是常见的WD特征性的临床表现,多见于有神经病变的患者.     

Unveiling endophthalmitis post COVID-19 – A case series

Since December 2019, coronavirus disease 2019 (COVID-19), caused by SARS-CoV-2, has become a global pandemic. There has been a resurgence in complications involving various organs in patients recovered from COVID-19, and endophthalmitis is one of them. Endophthalmitis—an inflammation of intraocular tissues leading to loss of vision or even loss of eye—has been a rare occurrence in the past, but has been on the rise in the post-COVID-19 times. Here we report seven such cases.     

Retinal manifestations in patients following COVID-19 infection: A consecutive case series

Purpose:To describe retinal manifestations seen in patients associated with COVID-19 infection at a multi-specialty tertiary care hospital in Southern India.Methods:In this retrospective chart review, all consecutive cases presenting to the Retina-Uveitis service from May 2020 to January 2021 with retinal manifestations associated with COVID-19 infection or its sequelae or as a result of treatment given for COVID-19 were included.Results:Of the 7 patients, 3 were female, and 4 were male. Four patients had onset of symptoms during the active phase of COVID-19 infection. Four had bilateral and three had unilateral involvement. The manifestations ranged from mild to vision threatening. Vision threatening manifestations included infections: endogenous endophthalmitis, candida retinitis and tubercular choroidal abscess and bilateral pre-foveal hemorrhages. Milder manifestations included paracentral acute middle maculopathy, central serous chorio-retinopathy and voriconazole induced visual symptoms. Final visual acuity was 6/36 or better in the four severe cases and 6/9 or better in the mild cases.Conclusion:This study highlights the retinal manifestations associated with COVID-19 infection and its sequelae. As these patients presented with an association with COVID-19 (either during or after recovery), ophthalmologists should be vigilant and screen for such entities in case of complaints of visual symptoms or in the presence of systemic sepsis. The outcomes can be good with prompt and aggressive management.     

Superior Ophthalmic Vein Thrombosis with Complete Loss of Vision as a Complication of Autoimmune and Infective Conditions

Purpose: To present our experience in the management of superior ophthalmic vein thrombosis (SOVT), which is a rare, but extremely serious condition if not recognized and managed promptly and appropriately.

Methods: Two patients with septic and aseptic SOVT are presented. Clinical characteristics, radiographic features, management techniques, and outcomes are described.

Results: In the first case thrombosis occurred as a complication of functional endoscopic sinus surgery. In the second case thrombosis occurred as a complication of untreated inflammatory bowel disease: ulcerative colitis. Both cases resulted with permanent unilateral blindness.

Conclusion: SOVT is a rare entity. There are no guidelines, just recommendations for disease management. Based on our experience, broad-spectrum intravenous antibiotic, anticoagulation, and steroid therapy should be promptly introduced and if needed surgical intervention. SOVT can lead to devastating complications which include permanent loss of vision and in some cases a fatal outcome.     

Wegener肉芽肿研究进展及眼部表现

Wegener肉芽肿(Wagener'sgranulomatosis,WG)是一种复杂的累及多系统的致死性疾病,对于以眼病首诊和仅有眼部表现的病例常因误诊而贻误治疗,新的具有较高特异性的检验技术应用及药物治疗进展,大大提高了对本病的诊治水平。强调全身用药的同时要早期进行眼科干预。近年来WG的发病机制,病理生理学改变,诊断标准,眼部的表现及治疗的研究现状和进展进行综述。     

Ophthalmic manifestations in patients with Leigh syndrome,French Canadian type

ABSTRACT

Background: Leigh syndrome, French Canadian type is a rare neurodegenerative disease. To our knowledge, there have been no studies based on ocular findings published for this disease. The purpose of this study is to describe ophthalmic findings in these patients.

Patients: Six patients genetically identified as having the syndrome were included in this study.

Methods: Four patients had an ophthalmic examination with an ophthalmologist including evaluation of visual acuity, extraocular motility and lid position, orthoptic workup, evaluation of stereopsis, refraction, evaluation of pupils, color vision, slit-lamp biomicroscopy, measurement of intraocular pressure, and fundoscopy. Two patients had a chart review.

Results: Visual acuity ranged from 0.00 logmar to 1.55 logmar. Extraocular motility abnormalities and ptosis were noted in half of the patients. Strabismus was present in the entire cohort, and stereopsis was absent in half of these patients. Amblyopia was noted in 83% of individuals and suppression in 33%. Only one patient had nystagmus. Refraction varied throughout patients. It included severe hyperopia, myopia, astigmatism, and significant anisometropia. Pupils, anterior segment, fundus, and color vision were normal in all patients. Intraocular pressure was slightly elevated in one patient.

Conclusion: Patients with Leigh syndrome, French Canadian type display a variety of ophthalmic findings, and screening at a young age is recommended.     

Ophthalmic presentations and long-term outcomes of subconjunctival and atypical orbital myocysticercosis

Purpose:To study the clinical presentation, radiological features, diagnosis, and treatment response in subconjunctival and atypical orbital myocysticercosis.Methods:Retrospective analysis of diagnosed subconjunctival and atypical (strabismus, diplopia, and blepharoptosis) orbital myocysticercosis was performed. A diagnostic criterion (2 of the 3) among clinical features, radiological findings, and treatment response was used in our study. A minimum of “post-treatment” follow-up of 12 months was observed.Results:Thirty-five patients were included with a mean age of 16 years having male predominance (n = 22, 62.8%). All had a unilateral presentation, with 24 (68.6%) patients having subconjunctival cysticercosis, of which 22 were located in close proximity of the rectus muscle insertion. At presentation, 10 patients had diplopia, 7 had strabismus, and 6 had face turn. Pseudo Duane’s and pseudo-Brown’s syndrome were noted in 5 and 4 patients, respectively. Radiologically, single muscle myositis without scolex was seen in 12 (34.3%) cases. All patients first received medical treatment, and surgical intervention (cyst removal) was attempted after treatment failure. Complete resolution of symptoms was noted in 22 (after medical treatment only) and in 8 (after surgery).Conclusion:In the majority, the subconjunctival cysticercosis is found in proximity to the rectus muscle insertion, as a part of orbital myocysticercosis. In atypical scenarios, a satisfactory response to medical treatment can be considered as diagnostic of cysticercosis.     

Septic superior ophthalmic vein thrombosis

An illustrative case of septic superior ophthalmic vein thrombosis secondary to a staphylococcus orbital cellulitis is presented and correlated with autopsy findings. A literature review and discussion of the risks and benefits of anti­coagulation in this setting is outlined.     

Ophthalmic practice during COVID-19 pandemic

AIM: To compare the visual acuity (VA), comfort, and patient preference in a soft toric contact lens (TCL) versus soft spherical contact lens (SCL) in low astigmatic subjects during the contact lens (CL) trial. METHODS: This subject-masked, block randomized, 2×2 crossover study recruited 40 neophyte subjects (80 eyes) aged 18 to 33y with astigmatism in the range of 0.75-1.25 D with or without spherical power from -6.00 D to +6.00 D. The participants were scheduled for two days CL trial and were fitted with the best-fit SCL and TCL. After 4h of wear, they were assessed objectively for high contrast VA and subjective vision, comfort, and preference. RESULTS: The responses of 36 subjects (response rate 90%) with a mean age of 23.02±2.97y (range 18 to 33y) were analysed. One-line improvement of monocular VA in the logMAR chart was reported to TCL as compared to SCL (-0.044±0.06 vs 0.04±0.03 logMAR, P=0.01) but the binocular vision remained similar (-0.12±0.07 vs -0.14±0.04 logMAR, P=0.38). Subjects felt a noticeable difference in clarity when shifted to TCL as compared to the SCL. The satisfaction with vision (vision quality) was significantly better with TCL (P=0.03). The fatigue with TCL was graded less at 2.5±0.6, compared to SCL at 4.6±1.3 (P=0.04). Thirty-three participants (91.6%) preferred to use contact lens of which 26 participants (79%) preferred TCL. CONCLUSION: The findings suggest that VA and comfort are better with TCL as compared to SCL which is only observed if the patient was offered both offering SCL with spherical equivalent power alone as the first option can mislead the practitioner; TCL trial should be the first choice of the lens in low-to-moderate astigmatism.     

武汉市确诊COVID-19眼科医务人员的眼部症状调查研究

目的 调查武汉眼科医务人员确诊COVID-19的眼部症状情况。设计 横断面问卷调查。研究对象 2020年2月26日至3月20日武汉确诊COVID-19的28例眼科医务人员为病例组，根据1:3~4的比例随机抽取病例组所在医院未感染的96例眼科医务人员作为对照组。方法 使用“问卷网”进行问卷调查。主要指标 被调查者的基本信息、新冠病毒核酸检测结果、眼部症状。结果 病例组26例（92.9%）及对照组96例（100%）完成问卷调查。病例组平均年龄（41.9±11.7）岁，分布在武汉10所综合性及眼科专科医院，确诊时间为2020年1月16日至2月29日；对照组平均年龄（35.1±5.5）岁。感染组中女性19例（67.9%）；医生14例（50%），护士12例（42.9%），技师2例（7.1%）；感染时从事眼科临床工作者19例（67.9%），从事抗疫一线工作者9例（32.1%）。病例组重症8例（28.6%）（包括死亡3例，危重症1例），咽拭子核酸检测阳性15例（53.6%）。病例组中25.7%的人认为工作环境通风条件较差。病例组11例（42.3%）有眼部症状，显著高于对照组（15.6%）（P=0.003）。其中，眼痒10例（90.9%）显著高于对照组（73.3%）（P=0.001），流泪4例（36.4%）显著高于对照组（13.3%）（P=0.02）；病例组异物感7例（63.6%），眼红2例（18.2%），视物模糊2例（18.2%）。4例行结膜囊核酸检测的患者中1例阳性。轻症20例中9例（45%）有眼部症状，重症6例中2例（33.3%）有眼部症状。结论 武汉眼科医务人员COVID-19患者中约40%存在眼部症状。尽管结膜囊新冠病毒核酸检测样本量少，但证实结膜囊中确实存在新冠病毒。（眼科， 2020， 29： 332-338）     

Macular hole: improved understanding of pathogenesis,staging, and management based on optical coherence tomography

Optical coherence tomography (OCT) has improved the understanding and management of idiopathic macular hole. Images of precursor lesions and their progression demonstrate that antero-posterior as well as tangential traction are involved in macular hole formation. The staging of macular holes with biomicroscopic examination can be paralleled by optical coherence tomography staging with some modification. OCT is useful in differentiating simulating lesions and in allowing better counseling of patients regarding their disorder. Finally, OCT findings are prognostic of surgical success and can assist in evaluating the results of surgery.     

Retinal manifestations of ophthalmic artery occlusion with ischemic stroke in a young patient with COVID-19

COVID-19-associated coagulopathy (CAC) has led to an increase in the incidence of large vessel stroke and cryptogenic shock. We present a case of a 30-year-old COVID-19-positive patient who developed an internal carotid artery (ICA) thrombosis, which led to ischemic stroke, aphasia, and unilateral blindness. Ophthalmic artery occlusion (OAO) was found to be the cause of vision loss. We thereby aim to highlight the detailed ophthalmic manifestations of OAO with features of posterior ciliary artery occlusion (PCAO) in this patient with proven ICA thrombosis.     

Impact of superior ophthalmic vein thrombosis: a case series and literature review

Purpose: To present nine new cases of superior ophthalmic vein thrombosis (SOVT) and compare these with the literature, and to assess the impact of SOVT for the clinician.

Methods: Using the data bases of the Department of Ophthalmology of the AMC, we searched for patients with radiologically evidenced SOVT between January 2006 and December 2014. In addition, a PubMed search, using the mesh term ‘superior ophthalmic vein thrombosis’, was done.

Results: We found nine patients with SOVT. In three patients, SOVT was related to dural arteriovenous fistulae. In one patient, it was caused by the acute reversal of warfarin by vitamin K. In two patients, an infectious cause was found. In three patients, the cause of SOVT was not found despite screening for coagulation and other disorders. All patients presented with eyelid swelling, proptosis, and/or motility impairment. We found complete recovery in four patients. Three patients had mild sequelae and two patients had severe visual impairment. In the literature, we found 60 cases reporting on SOVT with various aetiologies. Clinical presentation, treatment modalities, and outcomes were comparable to our findings.

Conclusion: Our case series and literature review show that SOVT can occur simultaneously with cavernous sinus thrombosis (CST) but can also be a separate entity. Clinical presentation can mimic orbital cellulitis (OC) or CST and when no signs of OC can be found, an alternative cause for SOVT should be sought. When timely and adequate treatment is conducted, the prognosis is predominantly favourable.     

Ophthalmic manifestations of Cryptococcus gattii species complex: a case series and review of the literature

AIM:To report 4 cases of Cryptococcus gattii(C.gattii)species complex infection with diverse ophthalmic manifestations,and to review the literature to examine pathobiology of disease,classical ophthalmic presentations and outcomes,and treatment modalities for this emerging pathogen.METHODS:Cases of C.gattii meningoencephalitis with ophthalmic manifestations were identified via chart review at two institutions in Australia and one institution in the mid-west region of the United States and are reported as a case series.Additionally,a MEDLINE literature review was conducted to identify all reported cases of C.gattii with ophthalmic manifestations from 1990-2020.Cases were reviewed and tabulated,together with our series of patients,in this report.RESULTS:Four cases of C.gattii with ophthalmic manifestations are presented;three from Australia and one from the USA.A literature review identified a total of 331 cases of C.gattii with visual sequelae.The majority of cases occurred in immunocompetent individuals.Blurred vision and diplopia were the most common presenting symptoms,with papilloedema the most common sign,reported in 10%-50%of cases.Visual loss was reported in 10%-53%of cases,as compared to rates of visual loss of 1%-9%in C.neoformans infection.Elevated intracranial pressure,cerebrospinal fluid(CSF)fungal burden,and abnormal neurological exam at presentation correlated with poor visual outcomes.The mainstays of treatment are anti-fungal agents and aggressive management of intracranial hypertension with serial lumbar punctures.CSF diversion procedures should be considered for refractory cases.Acetazolamide and mannitol are associated with high complication rates,and adjuvant corticosteroids have demonstrated higher mortality rates;these treatments should be avoided.CONCLUSION:Permanent visual loss represents a devastating yet potentially preventable sequelae of C.gattii infection.Intracranial hypertension needs to be recognised early and aggressively managed.Referral to an ophthalmologist/neuro-ophthalmologist in all cases of cryptococcal infection independent of visual symptoms at time of diagnosis is recommended.