Concurrent tonic pupil and trochlear nerve palsy in COVID-19

Ocular manifestations of COVID-19

There is an increasing body of knowledge regarding how COVID-19 may be associated with ocular disease of varying severity and duration. This article discusses the literature on the ocular manifestations associated with COVID-19, including appraisal of the current evidence, suggested mechanisms of action, associated comorbidities and risk factors, timing from initial infection to diagnosis and clinical red flags. The current literature primarily comprises case reports and case series which inevitably lack control groups and evidence to support causality. However, these early data have prompted the development of larger population-based and laboratory studies that are emerging. As new data become available, a better appraisal of the true effects of COVID-19 on the eye will be possible. While the COVID-19 pandemic was officially declared no longer a "global health emergency" by the World Health Organization (WHO) in May 2023, case numbers continue to rise. Reinfection with different variants is predicted to lead to a growing cumulative burden of disease, particularly as more chronic, multi-organ sequelae become apparent with potentially significant ocular implications. COVID-19 ocular manifestations are postulated to be due to three main mechanisms: firstly, there is a dysregulated immune response to the initial infection linked to inflammatory eye disease; secondly, patients with COVID-19 have a greater tendency towards a hypercoagulable state, leading to prothrombotic events; thirdly, patients with severe COVID-19 requiring hospitalisation and are immunosuppressed due to administered corticosteroids or comorbidities such as diabetes mellitus are at an increased risk of secondary infections, including endophthalmitis and rhino-orbital-mucormycosis. Reported ophthalmic associations with COVID-19, therefore, include a range of conditions such as conjunctivitis, scleritis, uveitis, endogenous endophthalmitis, corneal graft rejection, retinal artery and vein occlusion, non-arteritic ischaemic optic neuropathy, glaucoma, neurological and orbital sequelae. With the need to consider telemedicine consultation in view of COVID-19's infectivity, understanding the range of ocular conditions that may present during or following infection is essential to ensure patients are appropriately triaged, with prompt in-person ocular examination for management of potentially sight-threatening and life-threatening diseases.

The Review of Ophthalmic Symptoms in COVID-19

The COVID-19 pandemic caused by SARS-CoV-2 had a significant impact on the health of the global human population, affecting almost every human organ, including the organ of vision. Research focus on understanding the pathophysiology, identifying symptoms and complications of the disease. Eye-related pathologies are important foci of research due to the potential for direct impact of the virus. Ophthalmologists around the world are reporting various symptoms of eye infections and ocular pathologies associated with SARS-CoV-2. The review of ophthalmic symptoms was conducted to help physicians of various specialties recognize possible ophthalmic manifestations of this viral disease. A literature review was conducted from January 2020 to July 2023 in the PubMed, MEDLINE, Science Direct, Scopus, Scielo and Google Scholar databases. The review of the literature showed that conjunctivitis is the most common ophthalmic symptom observed during the course of COVID-19 and can occur at any stage of the disease. Changes in the eye may result from the direct effect of the virus, immune response, prothrombotic states, comorbidities, and medications used. Symptoms related to the organ of vision can be divided into: changes affecting the protective apparatus of the eye, the anterior eye segment, the posterior eye segment, neuro-ophthalmic, and orbital changes. Ocular symptoms may suggest COVID-19 infection or appear several weeks after recovery. Following COVID-19 vaccinations, a diverse range of ophthalmic symptoms was observed in various locations and at different times, mirroring the ocular symptoms experienced throughout the course of the COVID-19 illness. It is important for physicians of all specialties to be aware of possible potential connections between eye diseases and SARS-CoV-2, in order to effectively diagnose and treat patients.

Adie's tonic pupil after COVID-19: a case report and literature review

Objective: Various neurological complications have been reported after COVID-19. The study aimed to document an unusual case of Adie's tonic pupil following COVID-19. Methods: The study was a case report. Results: A 28-year-old female had suffered a flu-like disease about 2 months before and the SARSCoV-2 polymerase chain reaction test at that time was positive. Two weeks after infection she noticed an asymmetry between the pupils. The only pathological finding on examination was anisocoria with a larger left pupil in ambient light. Light reflexes were observed in the right eye, while in the left eye, they were absent. Also, there was no near response in the left pupil. A 0.1% pilocarpine test results validated Adie's pupil diagnosis. After one year of follow-up, the anisocoria decreased but did not completely recover. Discussion: COVID-19 may cause damage to neural structures due to autoimmune ways by activating immune pathways or because of vascular complications that may affect the vasa nervorum. Adie's tonic pupil is often idiopathic, but it may develop following viral infection. Conclusions: Ocular complications that involve pupil abnormalities may manifest following COVID-19. In the cases of Adie's tonic pupil, infectious diseases, including COVID-19, should be questioned. Abbreviations: RT PCR = reverse transcription polymerase chain reaction.

Update on coronavirus disease 2019: Ophthalmic Manifestations and Adverse Reactions to Vaccination

The coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 was one of the most devastating public health issues in recent decades. The ophthalmology community is as concerned about the COVID-19 pandemic as the global public health community is, as COVID-19 was recognized to affect multiple organs in the human body, including the eyes, early in the course of the outbreak. Ophthalmic manifestations of COVID-19 are highly variable and could range from mild ocular surface abnormalities to potentially sight and life-threatening orbital and neuro-ophthalmic diseases. Furthermore, ophthalmic manifestations may also be the presenting or the only findings in COVID-19 infections. Meanwhile, global vaccination campaigns to attain herd immunity in different populations are the major strategy to mitigate the pandemic. As novel vaccinations against COVID-19 emerged, so were reports on adverse ophthalmic reactions potentially related to such. As the world enters a post-pandemic state where COVID-19 continues to exist and evolve as an endemic globally, the ophthalmology community ought to be aware of and keep abreast of the latest knowledge of ophthalmic associations with COVID-19 and its vaccinations. This review is a summary of the latest literature on the ophthalmic manifestations of COVID-19 and the adverse ophthalmic reactions related to its vaccinations.

Pupillographic Analysis of COVID-19 Patients: Early and Late Results After Recovery

Objectives

We aimed to investigate the short- and long-term static and dynamic pupillary responses of patients recovered from coronavirus disease-19 (COVID-19) using quantitative infrared pupillography.

Methods

This study included patients who recovered from COVID-19 (Group 1) and age- and gender-matched controls (Group 2). A detailed ophthalmic examination was performed at 1 month and 6 months after the diagnosis of COVID-19. Photopic, mesopic, and scotopic pupil diameters (PDs) were measured using a quantitative infrared pupillography which was integrated into Scheimpflug/Placido photography-based topography system. PDs at 0, 2nd, 4th, and 6th seconds, and average pupil dilation speeds at 2nd, 4th, 6th, and 8th seconds were recorded.

Results

Eighty-six eyes of 86 patients (Group 1: n=42; Group 2: n=44) were included. While the mean photopic, mesopic, and scotopic PDs were significantly larger in the COVID-19 group than the control group in the 1st month (p=0.035, p=0.017, p=0.018, respectively), no statistically significant difference was found in the 6th month. Besides, average pupil dilation speeds and PDs at the 0, 2nd, 4th, and 6th seconds were not statistically significantly different between the two groups in the 1st month and 6th month.

Conclusion

PDs were significantly larger in COVID-19 patients in all light intensities in the 1st month after COVID-19. However, pupillary dilation was transient, and no significant difference was found in the 6th month. We suggest that the transient pupillary dilation may be secondary to the autonomic nervous system dysfunction and/or optic nerve and visual pathways alterations following COVID-19.

COVID-19 and sudden-onset ocular neurogenic palsy in prior healthy patients: a systematic review

BACKGROUND

The aim of this systematic review is to identify cases of neurogenic ocular palsy in the presence of COVID-19 and to document patient characteristics, type of palsy and possible aetiologies.

METHODS

A systematic search of PubMed, Medline and CINAHL databases was conducted on the 6th of January 2023 to identify cases of neurogenic ocular palsy in patients with current or previous COVID-19 infection. Data were pooled to summarise the neurogenic palsy, patient clinical characteristics and proposed palsy mechanisms.

RESULTS

The combined database search yielded 1197 articles. Of these, 23 publications consisting of 25 patients met the inclusion criteria. Most patients were male (68%) and ranged in age from 2 to 71 years (median=32.7, SD=21.4). Seven patients (28%) were children aged 2 to 10 years old. Abducens palsies were most common (68%) and the most common ocular presentation was diplopia (76%) with an average time of onset 15 days from testing positive to COVID-19 or having symptoms of the virus. Proposed mechanism of development of a neurogenic palsy secondary to COVID-19 infection was classified into one of three categories: vascular/thrombotic, a viral neuro-invasive or inflammatory virus-mediated immune response.

DISCUSSION

This study suggests that COVID-19 infection may be linked to oculomotor, trochlear and abducens nerve palsies and the underlying mechanisms may vary but are difficult to definitively establish. Further studies investigating the onset of neurogenic palsy secondary to COVID-19 infection is required.

Isen D, Tavakoli M. Neuro-ophthalmic Manifestations of Coronavirus Disease 2019 and Its Vaccination: A Narrative Review

Coronavirus disease 2019 (COVID-19) is a current pandemic caused by SARS-CoV-2 that has vastly affected the whole world. Although respiratory disease is the most common manifestation of COVID-19, the virus can affect multiple organs. Neurotropic aspects of the virus are increasingly unfolding, in so far as some respiratory failures are attributed to brainstem involvement. The neuro-ophthalmic manifestations of COVID-19 and the neuro-ophthalmic side effects of vaccination were reviewed. The major findings are that the SARS-CoV-2 infection commonly causes headaches and ocular pain. It can affect the afferent and efferent visual pathways by ischemic or inflammatory mechanisms. Optic nerve may be the origin of transient or permanent visual loss from papillophlebitis, idiopathic intracranial hypertension, or optic neuritis. Cerebrovascular strokes are not uncommon and may lead to cortical visual impairment or optic nerve infarction. SARS-CoV-2 may affect the pupillomotor pathways, resulting in tonic pupil (Adie's syndrome) or Horner's syndrome. Cranial neuropathies including third, fourth, sixth, and seventh nerve palsies have all been reported. Rhino-orbital mucormycosis superinfections in COVID-19 patients receiving steroids or other immunosuppressive therapies may result in unilateral or bilateral visual loss and ophthalmoplegia. Autoimmune conditions such as Guillain-Barré, Miller-Fisher syndrome, and ocular myasthenia have been reported.

An overview of third, fourth and sixth cranial nerve palsies in the setting of COVID-19: A case report and systematic review

BACKGROUND

Covid-19 has serious sequelae that may be poorly understood, underreported, and, as a result, not diagnosed promptly, such as variations in clinical manifestations of hyperinflammation among people infected with SARS-CoV-2. ophthalmoplegia can be one of these manifestations.

METHODS

We are reporting a 55-year-old male patient with unilateral diplopia considering it as a case of multisystem inflammatory syndrome in adults. We also reviewed the literature systematically for the previously reported studies/cases with third, fourth and sixth cranial nerve palsies due to or after Covid-19.

RESULTS

The literature search yielded 17 studies reporting 29 patients. 71.4% of the patients were males with a mean age of 42.23 years. Ophthalmological symptoms took 9.7 days to appear after the respiratory involvement. All patients had diplopia as part of their visual symptoms. 41.4% of the patients had unilateral sixth nerve palsy, 24% had bilateral sixth nerve involvement, 17% had fourth nerve involvement, and 27.6% had third nerve involvement.

CONCLUSION

Ophthalmoplegia is considered presenting symptom of Covid-19. Further research is needed to detect all neuro-ophthalmological manifestations of Covid-19.

Efferent neuro-ophthalmic complications of coronavirus disease 2019

PURPOSE OF REVIEW

We set out to describe efferent neuro-ophthalmological complications that have been reported in association with coronavirus disease 2019 (COVID-19) infection. We describe syndromes affecting ocular motility and elaborate on mechanisms of disease, including para-infectious inflammation, hypercoagulability, endothelial damage, and direct neurotropic viral invasion. Despite global vaccination programs, COVID-19 continues to pose an international threat that may rarely result in diplopia or nystagmus.

RECENT FINDINGS

Efferent complications include cranial nerve palsies leading to diplopia, either isolated or in association with Miller Fisher syndrome. Nystagmus has been observed in the setting of hemorrhagic acute necrotizing encephalopathy and brainstem infarcts, and opsoclonus syndrome has been described.

SUMMARY

Observed neuro-ophthalmic associations need to be confirmed through larger comparative studies. Meanwhile, the range of possible complications should be recognized by neurologists and ophthalmologists alike, to facilitate faster diagnosis and treatment of both COVID-19 and its neuro-ophthalmic manifestations.

A Comparison of the Incidence and Type of Ocular Motility Defects in Patients Presenting to Birmingham Midland Eye Centre Emergency Department during 2019 and 2020 to Assess the Impact of the Covid-19 Pandemic

Aim:

This audit aimed to investigate whether COVID-19 had any impact on the incidence and type of ocular motility defects in patients presenting to Birmingham Midland Eye Centre (BMEC) Emergency Department (ED) during the COVID-19 pandemic in 2020 compared to the previous year.

Methods:

Medical records were reviewed for all patients presenting to BMEC ED during 2019 and 2020. Patients were classified depending on their diagnosis. The incidence and classification of ocular motility defect were analysed. Factors considered during analysis were number of presentations by year and month; COVID-19 tests; and pre-existing conditions.

Results:

Two hundred and twenty-one patients presented in 2019, and 260 patients in 2020, an increase in incidence of 17.6% was observed. One hundred and eighty-five patients were classified with new-onset neurogenic conditions in 2019, and 222 patients in 2020, an increase of 20.0%. In 2020, most patients presented in July, November, and December. Overall, there was a 91.3% increase in new-onset fourth cranial nerve palsies in 2020. Fifty-seven patients in 2020 had a Polymerase Chain Reaction COVID-19 test, of these 5 were COVID-19 positive.

Conclusion:

There was a higher incidence of ocular motility defects in 2020 compared to 2019. The majority of ocular motility defects were classified as neurogenic. It is difficult to attribute this increase to COVID-19 due to lack of testing and results, and confounding variables such as pre-existing conditions and lockdown restrictions. Some potential explanations for the change in presentations across the year of 2020 are proposed.

Diplopia, COVID-19 and Vaccination: Results from a Cross-Sectional Study in Croatia

The aim of this study was to explore diplopia as a symptom of undetected COVID-19 infection or as a possible side effect of COVID-19 vaccination. We examined 380 patients with diplopia admitted to the Department of Ophthalmology of the University Hospital Centre Sestre milosrdnice in Zagreb, Croatia, from July 2020 to June 2022. After excluding patients with confirmed organic underlying diplopia causes or monocular diplopia, we linked the patient information with the national COVID-19 and vaccination registries. Among the 91 patients included in this study, previously undetected COVID-19 infection as the possible cause of diplopia was confirmed in five of them (5.5%). An additional nine patients (9.9%) were vaccinated within one month from the onset of their symptoms, while the remaining 77 had neither and were therefore considered as controls. The breakdown according to the mechanism of diplopia showed no substantial difference between the vaccinated patients and the controls. We detected marginally insignificant excess abducens nerve affection in the COVID-positive group compared with that in the controls (p = 0.051). Post-vaccination diplopia was equally common in patients who received vector-based or RNA-based vaccines (21.4 vs. 16.7%; p = 0.694). COVID-19 testing should be performed for all cases of otherwise unexplained diplopia. The risk of post-vaccination diplopia was similar in both types of vaccines administered, suggesting a lack of evidence linking specific vaccine types to diplopia.

Update on overview of ocular manifestations of COVID-19

The coronavirus disease 2019 (COVID-19) has become the most critical health crisis at present, and research is continued about the exact pathophysiology, presentations, and complications of this pandemic. It influences several organs, and many studies have addressed the organs, the involvement of which during the COVID-19 results in patients' death. One of the important organs that can be involved during COVID-19, which is also a transmission route of the disease, is the eye. According to the evidence, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can have ocular manifestations and complications. According to the literature, conjunctivitis is the most common presentation, which can develop at any stage of COVID-19 (during and even after the disease), and the major pathophysiology of the eye involvement during the disease is attributed to the direct effect of the virus on the eyes, tissue damage caused by inflammation, underlying diseases, and the adverse effect of the medications prescribed. There are also reports of life-threatening complications, such as rhino-orbital cerebral mucormycosis, which require urgent treatment and are associated with a great mortality rate. Ocular manifestations may also be the presentation of a life-threatening event, such as stroke; therefore, it is necessary to pay great attention to the ocular manifestations during COVID-19. In this review, after about 2 years of the pandemic started, we present a narrative review on ocular manifestations during COVID-19, categorized into three main categories; ophthalmic, orbital, and neuro-ophthalmological manifestations with a detailed description of the presenting symptoms, risk factor, diagnostic, and therapeutic strategies suggested for each.

Abducens and Trochlear Nerve Palsies After COVID-19 Vaccination: Report of Two Cases

The authors report two cases of an abducens palsy and a trochlear nerve palsy, respectively, in two patients who received a coronavirus disease 2019 (COVID-19) vaccine 2 weeks previously. Given the lack of other symptoms, normal test results, and spontaneous resolution of the diplopia, a likely association with the COVID-19 vaccine was suggested. [J Pediatr Ophthalmol Strabismus. 2022;59(5):e50-e53.].

How Does SARS-CoV-2 Affect Our Eyes-What Have We Learnt So Far about the Ophthalmic Manifestations of COVID-19?

The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection has become a worldwide threat resulting in a pandemic in 2020. SARS-CoV-2 infection manifests itself as coronavirus disease 2019 (COVID-19) that is evidenced in a vast number of either specific or nonspecific symptoms. Except for typical (but nonspecific) symptoms such as fever, dry cough, or muscle weakness, the infected patients might also present atypical symptoms including neurological, dermatological, or ophthalmic manifestations. This paper summarizes the current state of knowledge regarding the onset, progression, and types of ophthalmic symptoms induced by SARS-CoV-2 infection recognized amongst the infected patients.

How to Manage a Strabismus Clinic During the COVID-19 Pandemic; What is Really Urgent, What is Not?: A Single-Center Case Series from Turkey

Objectives:

To evaluate the management of the pediatric ophthalmology and strabismus clinic when strict quarantine conditions were adopted during the coronavirus disease 2019 (COVID-19) pandemic in Turkey.

Materials and Methods:

The study presents a review of the patients examined during the quarantine period. All patients were assessed with the highest possible level of personal protection.

Results:

Ten patients (6 girls, 4 boys) with a mean age of 9 years (range: 2-16) were evaluated. The patients presented 3-20 days after symptom onset. Ocular misalignment and diplopia were the main symptoms. Four of the 10 patients were diagnosed with sixth cranial nerve palsy and three patients were diagnosed with acute-onset comitant esotropia. Six patients had significant cranial magnetic resonance imaging findings.

Conclusion:

Acute-onset neurological conditions are more common during the COVID-19 pandemic. These reports will contribute to global experience and understanding of COVID-19.

Abnormal quantitative pupillary light responses following COVID-19

Purpose

To characterize alterations in pupillary light reflex responses in subjects following coronavirus disease 2019 (COVID-19), especially those with long-COVID.

Methods

Thirty-five subjects with previous COVID-19 and 30 healthy control participants were enrolled in this cross-sectional comparative study. An infrared dynamic pupillometry system (MonPack One; Metrovision, France) was used to quantify pupillary light responses. The National Institute for Health and Care Excellence (NICE) long-COVID questionnaire was used to identify persisting symptoms at least 4 weeks after acute COVID-19.

Results

The median time after the diagnosis of acute COVID-19 was 4.0 (2.0–5.0) months. There was an increase in the latency of pupil contraction (P = 0.001) and a reduction in the duration of pupil contraction (P = 0.039) in post-COVID-19 subjects compared to healthy controls. No significant differences were observed in the initial pupil diameter, amplitude and velocity of pupil contraction or latency, velocity and duration of pupil dilation. Long-COVID was present in 25/35 (71%) subjects and their duration of pupil contraction was reduced compared to subjects without long-COVID (P = 0.009). The NICE long-COVID questionnaire total score (ρ = − 0.507; P = 0.002) and neurological score (ρ = − 0.412; P = 0.014) correlated with the duration of pupil contraction and the total score correlated with the latency of dilation (ρ = − 0.352; P = 0.038).

Conclusion

Dynamic pupillometry reveals significant alterations in contractile pupillary light responses, indicative of parasympathetic dysfunction after COVID-19.

Neuro-Ophthalmic Implications of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Related Infection and Vaccination

ABSTRACT

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic created a unique opportunity to study the effects of infection and vaccination on disease. The year 2020 was dominated by infection and its consequences. The year 2021 was dominated by vaccination and its consequences. It will still take several years for full maturation of databases required for robust epidemiological studies. Therefore, this review on the implications for neuro-ophthalmology draws on resources presently available including reported adverse reactions to vaccination. Illustrative clinical cases are presented.The spectrum of pathology following infection with SARS-CoV-2 falls into 4 main categories: autoimmune, vascular, sequelae of brain damage, and miscellaneous. This review is exhaustive, but the most common conditions discussed relate to headaches and associated symptoms; vertigo, diplopia, and nystagmus; vascular complications of the eye and brain; cranial nerve (mono-)neuropathies; photophobia, ocular discomfort, and optic neuritis. Of the 36 main adverse reactions reviewed, vaccine-induced immune thrombotic thrombocytopenia is a novel complication requiring specific hematological management. Updated diagnostic criteria are summarized. It is relevant to remember taking a medication history because of side effects and to recognize the relevance of comorbidities. The clinical assessment can frequently be performed virtually. Consensus recommendations on telemedicine and the virtual assessment are summarized in a practical and compressed format.The review concludes with an epidemiological tetralogy to interrogate, in future studies, associations with (1) SARS-CoV-2 pandemic infection, (2) SARS-CoV-2 worldwide vaccination, and (3) the possibility of a rebound effect of infections in the pandemic aftermath.

Tonic Pupil Following COVID-19

ABSTRACT

A 37-year-old patient presented to our emergency department with sudden onset decreased vision with a history of being treated for COVID 19 3 weeks earlier. On examination, she was found to have a tonic right pupil, which was confirmed with a dilute pilocarpine test. As tonic pupils are known to be caused by neurotropic viruses and our current understanding of the SARS-CoV-2 is that it does affect the nervous system, we feel that the tonic pupil in our patient may be secondary to COVID 19.

COVID-19: Update on Its Ocular Involvements, and Complications From Its Treatments and Vaccinations

ABSTRACT

The coronavirus disease 2019 (COVID-19) came under the attention of the international medical community when China first notified the World Health Organization of a pneumonia outbreak of then-unknown etiology in Wuhan in December 2019. Since then, COVID-19 caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has appalled the world by spreading at a pandemic speed. Although ophthalmologists do not directly engage in the clinical care of COVID-19 patients, the ophthalmology community has become aware of the close ties between its practice and the pandemic. Not only are ophthalmologists at heightened risk of SARS-CoV-2 exposure due to their physical proximity with patients in routine ophthalmic examinations, but SARS-CoV-2 possesses ocular tropism resulting in ocular complications beyond the respiratory tract after viral exposure. Furthermore, patients could potentially suffer from adverse ocular effects in the therapeutic process. This review summarized the latest literature to cover the ophthalmic manifestations, effects of treatments, and vaccinations on the eye to aid the frontline clinicians in providing effective ophthalmic care to COVID-19 patients as the pandemic continues to evolve.

Pupil responses in patients with COVID-19

Aim

To compare pupillary responses in patients with Coronavirus disease-2019 (COVID-19) during active infection and at 3rd months post-infection.

Methods

This study included 58 COVID-19 cases (mean age 47.23 ± 1.1 years). The scotopic, mesopic and photopic diameters were noted. Pupil diameters were noted at the 0, 1st, 2nd, 4th, 6th, 8th, and 10th seconds in reflex pupil dilation after the termination of a light. The average dilation speed was calculated at the 1st, 2nd, 4th, 6th, 8th, and 10th seconds. Pupil responses measured during COVID-19 infection and 3 months later were compared.

Results

The mean scotopic and mesopic pupil diameter value of during COVID-19 infection was found lower than the 3rd month post-infection. (p = 0.001, p = 0.023; respectively). No statistically significant difference was found in the mean photopic pupil diameter and the mean pupil diameter at 0 s between measurements (p > 0.05, p = 0.734; respectively). The mean pupil diameter was significantly lower during COVID-19 infection at the 1st, 2nd, 4th, 6th, 8th and 10th seconds (p < 0.01, for each). The average dilation speed measurements at every second measured were lower in during COVID-19 infection than the 3rd months later (p = 0.001; p < 0.01 for each).

Conclusions

Pupil responses were found significantly different in COVID-19 cases when compared with the measurements taken three months later.

Tonic pupil after COVID-19 infection

The latest global health threat is the ongoing outbreak of respiratory disease, which was named COVID-19 and multiple ever-evolving neurological complications have since been reported. We present the case of a patient with a bilateral tonic pupil in the postinfectious context of COVID 19. Brain magnetic resonance imaging and laboratory tests were normal, a 0.125% pilocarpine test confirmed the diagnosis.

Pupila tónica después de la infección por COVID-19

La última amenaza para la salud a nivel mundial es el continuo brote de la enfermedad respiratoria, que recibió el nombre de COVID-19, y desde entonces se han publicado múltiples complicaciones neurológicas que están en constante evolución. Presentamos el caso de un paciente con pupila tónica bilateral en el contexto postinfeccioso de COVID-19. La resonancia magnética cerebral y los estudios analíticos fueron normales, una prueba de pilocarpina al 0,125% confirmó el diagnóstico.

Internuclear ophthalmoplegia as a presenting feature in a COVID-19-positive patient

A 58-year-old man presented with vertical diplopia for 10 days which was sudden in onset. Extraocular movement examination revealed findings suggestive of internuclear ophthalmoplegia. Investigations were suggestive of diabetes mellitus, and reverse transcription-PCR for SARS-CoV-2 was positive. At 3 weeks of follow-up, his diplopia had resolved. Neuro-ophthalmic manifestations in COVID-19 are increasingly being recognised around the world. Ophthalmoplegia due to cranial nerve palsy and cerebrovascular accident in COVID-19 has been reported. We report a case of internuclear ophthalmoplegia in a patient with COVID-19.

Clinical and Pathophysiologic Spectrum of Neuro-COVID

Though the lungs are predominantly affected in SARS-CoV-2-infected patients, extra-pulmonary manifestations can occur. Extra-pulmonary manifestations of the central and peripheral nervous system need to be recognised as they can strongly determine the outcome. This mini-review summarises and discusses previous and recent findings about neuro-COVID. The spectrum of central nervous system disease in COVID-19 patients is much broader than so far anticipated. Peripheral nerves and the skeletal muscle are less predominantly affected. In the vast majority of the cases, there is no direct attack of the virus towards vulnerable structures, which explains why various manifestations of the nervous system manifest favourably to immune suppression or immune modulation. Overall, the pathophysiology and clinical presentation of CNS/PNS involvement in COVID-19 is wider than believed. All patients with COVID-19 should be investigated by the neurologist for primary or secondary involvement of the CNS/PNS in the infection. neuro-COVID responds favourably to immune suppressants or immune modulation.

Adie-Holmes syndrome associated with COVID-19 infection: A case report

With increasing experience, it has been suggested that the SARS-CoV-2 virus has a neurotropic effect. Here, we present a case of a tonic pupil who developed after COVID-19 infection. A 36-year-old woman presented with progressive photophobia and blurred vision. On neurological examination, loss of deep tendon reflexes accompanying a tonic pupil was detected and brain MR imaging was normal. With this case, we aimed to describe a rare pattern of neurological involvement caused by the possible SARS-CoV-2 virus.

Evidence of SARS-CoV-2 Transmission Through the Ocular Route

PURPOSE

Currently, the coronavirus disease 2019 (COVID-19) pandemic is raging around the world. However, the transmission of its pathogen, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is not fully clear. It is still controversial whether the ocular transmission of SARS-CoV-2 exists. This review aimed to summarize the evidence of SARS-CoV-2 ocular transmission.

METHODS

Online articles were searched till October 23, 2020 in Pubmed, Embase, and websites of World Health Organization, Centers for Disease Control and Prevention COVID-19, American Academy of Ophthalmology, and American Society of Cataract and Refractive Surgery under the search strategy of (((("COVID-19"[Mesh]) OR ("SARS-CoV-2"[Mesh])) OR (2019 novel coronavirus)) OR (2019-nCoV)) AND (((("Conjunctivitis"[Mesh]) OR (Ocular Surface)) OR ("Eye"[Mesh])) OR ("Ophthalmology"[Mesh])). The language was not restricted. After screening, 1445 records were excluded and 168 references original articles were finally included.

RESULTS

Cells of ocular surface express both the receptor of angiotensin-converting enzyme 2 (ACE2) and transmembrane serine protease 2 (TMPRSS2), offering molecular bases for the ocular susceptibility to SARS-CoV-2. Accumulated COVID-19 patients presented conjunctivitis as the initial or the only symptom. Whether COVID-19 patients had ocular symptoms or not, SARS-CoV-2 was detectable on the ocular surface, and the isolated virus was infectious, proving that the ocular surface can not only be a reservoir but also a source of contagion. SARS-CoV-2 may reach the ocular surface by hand-eye contact and aerosols. Once SARS-CoV-2 reaches the ocular surface, it may transfer to other systems through the nasolacrimal system or hematogenous metastasis.

CONCLUSION

The ocular surface can serve as a reservoir and source of contagion for SARS-CoV-2. SARS-CoV-2 can be transmitted to the ocular surface through hand-eye contact and aerosols, and then transfer to other systems through nasolacrimal route and hematogenous metastasis. The possibility of ocular transmission of SARS-CoV-2 cannot be ignored.