Episcleritis as a possible presenting sign of the novel coronavirus disease: A case report

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.

Ocular Implications of COVID-19 Infection and Vaccine-Related Adverse Events

The COVID-19 pandemic, caused by SARS-CoV-2, has significantly impacted various organ systems, including the eyes. Initially considered a primarily respiratory disease, it is now evident that COVID-19 can induce a range of ocular symptoms. Recognizing these ocular manifestations is crucial for eye care practitioners as they can serve as early indicators of the disease. This review consolidates current evidence on the ocular effects of COVID-19, identifying manifestations such as conjunctivitis, scleritis, uveitis, and retinopathy. The increasing prevalence of these symptoms highlights the importance of thorough eye examinations and detailed patient histories in COVID-19 cases. Potential routes of viral entry into ocular tissues and the underlying mechanisms, including direct infection, immune responses, and vascular involvement, are explored. Additionally, this review addresses ocular side effects associated with COVID-19 vaccines, such as corneal graft rejection, uveitis, and retinal issues. These findings emphasize the need for ongoing surveillance and research to ensure vaccine safety.

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.

COVID-19 and Its Ophthalmic Manifestations: A Literature Review

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus discovered in late 2019 in Wuhan, Hubei Province, China. The virus has now developed into a full-scale global pandemic affecting hundreds of millions of people to date. A majority of cases present with nonspecific acute upper respiratory symptoms. A wide range of systemic symptoms has been reported, with some patients presenting with nonspecific extrapulmonary symptoms. Recently, there has been an increased association of COVID-19-positive patients presenting with ocular symptoms. As an increasing number of patients present with ophthalmic manifestations, recognizing these visual symptoms is of utmost importance. Some patients may present with ocular symptoms as the first indication of COVID-19 infection; quickly isolating and starting treatment can aid in stopping the spread of this novel coronavirus. This review will describe the current epidemiology and pathophysiology of SARS-CoV-2, emphasizing the ophthalmic manifestations and their clinical course progression. Further, we will be reporting on the growing number of rare ocular manifestations that have occurred in some COVID-19-positive patients, along with the route of transmission, specific manifestations, and the treatment methods for both these pulmonary and extrapulmonary symptoms, specifically the ocular manifestations.

Acute macular neuroretinopathy and COVID-19 or SARS-CoV-2 infection: case report and literature review

Purpose

To describe a case of acute macular neuroretinopathy (AMN) associated with COVID-19 infection and a related literature review.

Methods

A case from the First Affiliated Hospital of Chongqing Medical University was reported that could be linked to COVID-19 or SARS-CoV-2 infection. We performed a comprehensive search on PubMed, retrieving articles containing information on AMN after COVID-19 or SARS-CoV-2 infection. The key words used were 'COVID-19', 'SARS-CoV-2', 'ophthalmic manifestations', 'acute macular neuroretinopathy', and 'paracentral scotomas'. The relevant data were extracted, charted, consolidated, and evaluated. Moreover, manual exploration of the reference lists of pertinent articles was carried out.

Results

We describe the case of a 30-year-old young woman who developed bilateral AMN one day after being infected with COVID-19 or SARS-CoV-2. She had severe visual impairment (20/2000 OD and 20/32 OS), and her vision recovered after taking oral corticosteroids. After reviewing the literature, we summarized 16 relevant reports and found that symptoms of AMN tend to arise 1 day to 1 month after COVID-19 or SARS-CoV-2 infection. Contraceptive pills and other risk factors should be avoided to reduce the risk of adverse outcomes. Oral prednisone may be an effective treatment for those experiencing important vision loss.

Conclusion

Symptoms of AMN can arise 1 day to 1 month after COVID-19 or SARS-CoV-2 infection. Ophthalmologists should remain vigilant about this disease, notably because patient characteristics may deviate from the norm.

Viral infections and pathogenesis of glaucoma: a comprehensive review

Glaucoma is a leading cause of irreversible blindness worldwide, caused by the gradual degeneration of retinal ganglion cells and their axons. While glaucoma is primarily considered a genetic and age-related disease, some inflammatory conditions, such as uveitis and viral-induced anterior segment inflammation, cause secondary or uveitic glaucoma. Viruses are predominant ocular pathogens and can impose both acute and chronic pathological insults to the human eye. Many viruses, including herpes simplex virus, varicella-zoster virus, cytomegalovirus, rubella virus, dengue virus, chikungunya virus, Ebola virus, and, more recently, Zika virus (ZIKV) and severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), have been associated with sequela of either primary or secondary glaucoma. Epidemiological and clinical studies suggest the association between these viruses and subsequent glaucoma development. Despite this, the ocular manifestation and sequela of viral infections are not well understood. In fact, the association of viruses with glaucoma is considered relatively uncommon in part due to underreporting and/or lack of long-term follow-up studies. In recent years, literature on the pathological spectrum of emerging viral infections, such as ZIKV and SARS-CoV-2, has strengthened this proposition and renewed research activity in this area. Clinical studies from endemic regions as well as laboratory and preclinical investigations demonstrate a strong link between an infectious trigger and development of glaucomatous pathology. In this article, we review the current understanding of the field with a particular focus on viruses and their association with the pathogenesis of glaucoma.

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.

[Ophthalmic manifestations of COVID-19]

In March 2020 the World Health Organization (WHO) declared a pandemic of the novel coronavirus infection (COVID-19) caused by the SARS-CoV-2 respiratory virus. The high spread rate of the virus and the severity of the course of the disease are of great clinical and epidemiological significance, making it relevant for ophthalmologists to study the mechanisms of how SARS-CoV-2 infects ocular structures, as well as possible clinical manifestations of the infection in the organ of vision. This review contains analysis, systematization, and generalization of epidemiological and clinical data on SARS-CoV-2 ocular lesions and was carried out with the data found in scientific abstract databases. The article presents main clinical ophthalmic manifestations of COVID-19, lists the utilized schemes of etiotropic and symptomatic therapy, recommended preventive measures, and considers the possible ophthalmic complications after vaccination against COVID-19.

Eye damage in COVID-19. Part 1: Involvement of the eye in SARS-CoV-2 virus transmission and anterior segment complications

In COVID-19, eye damage may develop at any stage of the disease. Viral ribonucleic acid has been found in ocular tissues, but the role of the eye as a route of infection is yet to be substantiated. Ophthalmic manifestations may be a typical feature of COVID-19 infection or they may develop several weeks after recovery. Ophthalmologists should be aware of possible relationships of an ophthalmic pathology with SARS-CoV-2 in order to obtain targeted case history, detect the specific signs, prescribe the necessary tests and thereby reduce the spread of the infection. These relationships are also important for early diagnosis and treatment of complications that threaten the patients’ life and vision. The first part of the review focuses on the possible involvement of the eye in SARS-CoV-2 infection and the spread of infection. Clinical manifestations of the anterior segment damage are considered.

[German S1 Guideline Long-/Post-COVID]

The German Society of Pneumology initiated 2021 the AWMF S1 guideline Long COVID/Post-COVID. In a broad interdisciplinary approach, this S1 guideline was designed based on the current state of knowledge.The clinical recommendations describe current Long COVID/Post-COVID symptoms, diagnostic approaches, and therapies.In addition to the general and consensus introduction, a subject-specific approach was taken to summarize the current state of knowledge.The guideline has an explicit practical claim and will be developed and adapted by the author team based on the current increase in knowledge.

Ocular manifestations of COVID-19 in the pediatric age group

The coronavirus disease 2019 (COVID-19) is now known to be associated with several ocular manifestations. The literature thoroughly discussed those that affect adults, with a lesser focus in the pediatric age group. We aim to outline the various pediatric ocular manifestations described in the literature. The manifestations may be divided into isolated events attributed to COVID-19 or occurring in the new multisystem inflammatory syndrome in children (MIS-C), a novel entity associated by COVID-19 infection. Ocular manifestations have virtually affected all ages. They manifested in neonates, infants, children, and adolescents. Episcleritis, conjunctivitis, optic neuritis, cranial nerve palsies, retinal vein occlusion, retinal vasculitis, retinal changes, orbital myositis, orbital cellulitis were reported in the literature with this emerging viral illness. Conjunctivitis was the most common ocular manifestation in MIS-C in nearly half of the patients. Other ocular manifestations in MIS-C were anterior uveitis, corneal epitheliopathy, optic neuritis, idiopathic intracranial hypertension, and retinitis. The clinical outcome was favorable, and children regain their visual ability with minimal or no deficits in most of the cases. Further follow-up may be warranted to better understand the long-term effects and visual prognosis.

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.

COVID-19 and the elderly

COVID-19 has become a great burden of the world in respect of health care, social, and economical reason. Several million people died worldwide so far and more and more mutants are generated and spread. Older people with co-morbidities and frailty syndrome have a significantly higher risk to get the infection and also higher the risk of a more serious disease process. Mortality of COVID-19 is also higher in case of geriatric patients. In this review we attempted to summarize the factors of the higher susceptibility for more serious disease, what actions need to be taken for defending older patients and also special aspects of clinical presentation including ophthalmic symptoms.

Recurrent Anterior Non-necrotizing Scleritis as an Adverse Event of ChAdOx1 nCoV-19 (Vaxzevria) Vaccine

PURPOSE

To describe a case of anterior scleritis related to SARS-CoV-2 vaccine. SARS-CoV-2 vaccines appear safe; however vaccination has triggered thromboembolic events in predisposed patients.

METHODS

A retrospective case report of anterior scleritis in a woman following administration of both ChAdOx1nCoV-19 vaccine doses was studied by complete ophthalmologic examination and complementary tests.

RESULTS

The patient has overcome SARS-CoV-2 infection a year prior. Ancillary tests including autoimmune and infectious diseases were negative. The chronology between ChAdOx1nCoV-19 vaccine and the sequential episodes of scleritis may have a cause-and-effect relationship.

CONCLUSION

Ophthalmologists may be aware of scleritis as an ocular manifestation following ChAdOx1nCoV-19 vaccine, in otherwise healthy patients.

Acute-onset dacryoadenitis following immunisation with mRNA COVID-19 vaccine

A 14-year-old boy was referred to the ophthalmology department with a 4-day history of rapid-onset right upper lid pain, swelling and erythema starting 9 hours after his first dose of COVID-19 mRNA vaccination (BNT162b2/Comirnaty, Pfizer-BioNTech). On examination, he had significant right upper lid ptosis, oedema and erythema, with associated limitation of right eye abduction and elevation. He was found to have acute dacryoadenitis with orbital inflammatory disease on clinical and laboratory investigations. He was given tapering oral prednisone and had full resolution of symptoms within 2 weeks. This is the first known case of orbital inflammation after COVID-19 mRNA vaccination. Given the temporal association between the patient’s vaccination and symptom onset, we believe it is likely that immunisation prompted the onset of disease.

Coronavirus Disease 2019, Eye Pain, Headache, and Beyond

BACKGROUND

Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), which causes Coronavirus Disease 2019 (COVID-19), emerged in December 2019 and became a devastating pandemic. Although its respiratory effects can be deadly and debilitating, it can lead to other systemic disorders, such as those causing eye pain and headache. This literature review aims to describe presentations of eye pain and headache in relation to COVID-19, with an emphasis on how these disorders help us to understand the pathophysiology of COVID-19.

EVIDENCE ACQUISITION

Literature was mined from the PubMed database using the key terms: "eye pain," "conjunctivitis," "episcleritis," "optic neuritis," "migraine," and "headache" in conjunction with "COVID-19" and "SARS-CoV-2." With the exception of general background pathology, articles that predated 2006 were excluded. Case reports, literature reviews, and meta-analyses were all included. Where SARS-CoV-2 research was deficient, pathology of other known viruses was considered. Reports of ocular manifestations of vision loss in the absence of eye pain were excluded. The primary search was conducted in June 2021.

RESULTS

The literature search led to a focused review of COVID-19 associated with conjunctivitis, episcleritis, scleritis, optic neuritis, and myelin oligodendrocyte glycoprotein-associated optic neuritis. Four distinct COVID-19-related headache phenotypes were identified and discussed.

CONCLUSIONS

Eye pain in the setting of COVID-19 presents as conjunctivitis, episcleritis, scleritis, or optic neuritis. These presentations add to a more complete picture of SARS-CoV-2 viral transmission and mechanism of host infection. Furthermore, eye pain during COVID-19 may provide evidence of hypersensitivity-type reactions, neurovirulence, and incitement of either novel or subclinical autoimmune processes. In addition, investigation of headaches associated with COVID-19 demonstrated 4 distinct phenotypes that follow third edition of the International Classification of Headache Disorders categories: headaches associated with personal protective equipment, migraine, tension-type headaches, and COVID-19-specific headache. Early identification of headache class could assist in predicting the clinical course of disease. Finally, investigation into the COVID-19-associated headache phenotype of those with a history of migraine may have broader implications, adding to a more general understanding of migraine pathology.

The Eye of the Storm: COVID-19 Vaccination and the Eye

The COVID-19 pandemic has galvanized the global response towards the development of new vaccines based on novel technologies at an unprecedented pace. Since the widespread implementation of vaccination campaigns, case reports on vaccines' systemic side effects, including ocular manifestations, have emerged. Since administered vaccines are generally not able to cause the disease in the recipient, or induce an immune response against the pathogen, we hypothesize that the development of ocular phenomena post-COVID-19 vaccination may occur via an immune response elicited by the vaccine. Of many, the most common ocular adverse events include facial nerve palsy, central venous sinus thrombosis and acute anterior uveitis. These COVID-19 vaccine-induced ocular (CVIO) adverse events could resemble the ocular findings in some of the COVID-19 patients. This review will provide a comprehensive overview of published ocular side effects potentially associated with COVID-19 vaccination and serve as a springboard for further research into CVIO adverse events.

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.

Impact of the COVID-19 Lockdown on Ophthalmological Assistance in the Emergency Department at a Spanish Primary Level Hospital

PURPOSE

To analyze the changes in ophthalmological emergencies during the COVID-19 pandemic lockdown at a Spanish primary level hospital.

METHODS

The number and type of emergencies attended in the emergency department of Hospital Universitario del Henares between March 10 and August 31, 2020 (COVID-19 cohort) were compared with the emergencies attended during the same period of 2019 (pre-COVID-19 cohort). Data on the diagnosis, patient age, and gender was retrospectively collected from the electronic medical records of the hospital. The different diagnoses were organized into "clusters," which include those conditions that affect the same ocular tissue and that have similar clinical expression.

RESULTS

The number of ophthalmological emergencies during the study period was 841, compared to 1343 during the same month of 2019, which represents a reduction of 37.4%. The percentage reduction in each cluster was as follows: conjunctiva (-65.4%), cornea (-35.8%), uveitis (-3.6%), eyelid and orbital and lacrimal (-35.5%), strabismus (-60%), neuro-ophthalmology (-11.8%), retina (-10.6%), cataract (+16.4%), glaucoma (-37%), and miscellaneous (-45.1%). The number of people seen with viral conjunctivitis decreased by -87.1% compared to 2019. Patients with complications due to conjunctivitis also decreased: patients with pseudomembranes dropped from 16 to 4 cases and patients with corneal subepithelial infiltrates from 9 to 3 cases.

CONCLUSIONS

Most diagnostic clusters showed a similar decrease. Clusters that included vision-threating conditions (retina, neuro-ophthalmology, and uveitis) remained mostly stable. During the COVID-19 lockdown, the diagnosis of adenoviral conjunctivitis decreased nearly 10 times. This fact may represent a decrease in the transmission of these infections.

COVID-19 and the Eye: Ocular Manifestations, Treatment and Protection Measures

The novel pandemic coronavirus disease 2019 (COVID-19) leading to health and economic problems worldwide is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although COVID-19 mainly occurs as a lower respiratory tract infection, there is multiorgan involvement in infected patients. The disease is transmitted from person to person through air droplets or contact with contaminated surfaces. SARS-CoV-2 leads to this systemic involvement by attaching to angiotensin-converting enzyme 2 (ACE2) receptors located on several human cells. Since SARS-CoV-2 RNA has been found in tears of infected patients, ocular surface may allow the virus to transmit to nasopharynx via the nasolacrimal duct. This narrative review aims to sum up all segmental ocular complications, ocular adverse effects of COVID-19 treatment, and preventive measures suggested to minimize the SARS-CoV-2 transmission between patients and ophthalmologists by reviewing currently available literature.

SARS-CoV-2 and the Eyes: A Review of the Literature on Transmission, Detection, and Ocular Manifestations

During the coronavirus disease 2019 (COVID-19) pandemic, numerous reports of ocular anomalies occurring in patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have emerged. The most frequently reported pathology is conjunctivitis, which may be the first or only clinical manifestation of the disease. Involvement of SARS-CoV-2 in development of alterations in other ocular structures was suggested, including the cornea, the retina, and blood vessels. Possible mechanisms include direct activity of the viral agent, as well as systemic inflammatory response with accompanying thromboembolic complications. Genetic material of SARS-CoV-2 was detected in ocular secretions of infected individuals, including asymptomatic patients. Moreover, angiotensin-converting enzyme 2 (ACE2), a receptor protein used by the virus to enter the cell, has been found on the surface of various structures of the eye, which indicates a risk of transmission through ocular tissues. Therefore, it is crucial to use eye protection by medical professionals having contact with potentially infected patients. This paper is a review of the literature regarding ocular manifestations of SARS-CoV-2 infection and a summary of the current state of knowledge about possibility of transmission from an ophthalmology point of view. For data collection, a thorough PubMed search was performed, using the key words: "COVID ocular", "COVID eye", "SARS-CoV-2 ocular", and "SARS-CoV-2 eye". Conclusions: SARS-CoV-2 infection may manifest itself in various ocular conditions. Eye protection should not be neglected, as recent studies suggest the eye as a potential route of transmission. Further search for adequate safety measures in ophthalmology practice is required.

Ocular Involvement in COVID-19: Conjunctivitis and More

Since the beginning of 2020, SARS-CoV-2, the pathogen of COVID-19, has led to a global pandemic that also affects ophthalmology. Ophthalmologists can be confronted at any time with potentially COVID-19 associated ocular symptoms or manifestations in patients and also become infected through close patient contact. Even without systemic infection, the ocular surface can come into direct contact with aerosols or liquids containing SARS-CoV-2 particles. A smear infection through hand-to-eye contact is also possible. A purely isolated ocular infection has not yet been shown. Rather, it seems that ocular complications occur in the context of a systemic infection. However, ocular symptoms can also be the first symptom of COVID-19. The most common ocular complication of COVID-19 is mild follicular conjunctivitis. Haemorrhagic conjunctivitis, dry eye disease, episcleritis, or retinal involvement can also occur less frequently. There are currently no evidence-based therapy recommendations for COVID-19 associated diseases of the ocular surface. Artificial tears might be helpful for symptom relief. There is no evidence for antiviral, antibiotic, or anti-inflammatory therapies, but these medications might be used in individual cases. Potential intraocular complications include retinal artery occlusions and haemorrhages, as well as cotton wool spots caused by complement-mediated thrombotic angiopathy. Neuro-ophthalmological complications including Miller-Fisher syndrome or infarct-related central blindness can also occur in very rare cases. Knowledge of potential transmission routes and personal protective equipment is just as essential for each ophthalmologist as a basic knowledge of potential ocular symptoms and complications.

Aseptic Meningitis after Recovery from SARS-CoV-2 in an Allogeneic Stem Cell Transplant Recipient

SARS-CoV-2 emerged as a worldwide pandemic in late 2019 and initially was described as a primary respiratory illness. The clinical manifestations of COVID-19 are now known to encompass nearly all organ systems, including the central nervous system. We present a case of an allogeneic hematopoietic stem cell transplant recipient who recovered from documented SARS-CoV-2 infection and later presented with symptoms of meningitis. While cerebrospinal fluid analysis did not reveal any bacterial or viral etiologies, evidence of an inflammatory state, including ophthalmologic findings of episcleritis, indicate what is likely the first reported case of aseptic meningitis associated with SARS-CoV-2 infection after initial clinical recovery.

An Update on COVID-19 Related Ophthalmic Manifestations

Purpose: To summarize ophthalmic manifestations of coronavirus disease (COVID-19) reported in the literature thus far.Methods: The PubMed database was systematically searched through October 24, 2020, to identify relevant articles using the following search terms: ("COVID-19" OR "SARS-CoV-2") AND ("eye" OR "ophthalmology" OR "retina" OR "retinal findings" OR "cornea" OR "conjunctiva"). Only articles published in English were included in this review.Results: The reported prevalence of ophthalmic manifestations is generally low, but correlates positively with the severity of the disease. Most commonly reported ocular manifestations are conjunctivitis, conjunctival hyperemia and chemosis. Retinal findings include microhemorrhages and flame-shaped hemorrhages, cotton wool spots, dilated veins, and tortuous vessels.Conclusion: Considering the COVID-19 cases have reached pandemic dimensions and are surging, yet again, it is of utmost importance to determine its ophthalmic manifestations and prevent their vision threatening complications. Further studies are warranted to establish whether the retinal findings appear due to the COVID-19 or are an incidental finding in patients with a preexisting diabetic or hypertensive retinopathy.

The Transmission of SARS-CoV-2 Infection on the Ocular Surface and Prevention Strategies

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a global health problem. Although the respiratory system is the main impaired organ, conjunctivitis is one of its common findings. However, it is not yet understood if SARS-CoV-2 can infect the eye and if the ocular surface can be a potential route of SARS-CoV-2 transmissions. Our review focuses on the viral entry mechanisms to give a better understanding of the interaction between SARS-CoV-2 and the eye. We highlighted findings that give evidence for multiple potential receptors of SARS-CoV-2 on the ocular surface. Additionally, we focused on data concerning the detection of viral RNA and its spike protein in the various ocular tissues from patients. However, the expression level seemed to be relatively low compared to the respiratory tissues as a result of a unique environment surrounding the ocular surface and the innate immune response of SARS-CoV-2. Nevertheless, our review suggests the ocular surface as a potential route for SARS-CoV-2 transmission, and as a result of this study we strongly recommend the protection of the eyes for ophthalmologists and patients at risk.

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.

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.