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

Corneal Stroma Analysis and Related Ocular Manifestations in Recovered COVID-19 Patients

Purpose

The purpose of this study was to assess the impact of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) on corneal stroma characteristics, ocular manifestations, and post-recovery refractive surgery outcomes after varying recovery durations.

Methods

Fresh corneal lenticules from patients with post-coronavirus disease 2019 (COVID-19; recovered within 135 days) and healthy controls (HCs) after small incision lenticule extraction (SMILE) surgery were obtained for experimental validation of SARS-CoV-2 susceptibility, morphological changes, and immune response of the corneal stroma. Corneal optical density (CD) was measured using the Pentacam HR. Corneal epithelium thickness (ET) and endothelium parameters were evaluated by wide-field optical coherence tomography (OCT) and non-contact specular microscopy (SP-1P), respectively. All the patients were assessed after SMILE surgery until 3 month of follow-up.

Results

The cornea was susceptible to SARS-CoV-2 with the presence of SARS-CoV-2 receptors (CD147 and ACE2) and spike protein remnants (4 out of 58) in post-recovery corneal lenticules. Moreover, SARS-CoV-2 infection triggered immune responses in the corneal stroma, with elevated IL-6 levels observed between 45 and 75 days post-recovery, which were then lower at around day 105. Concurrently, corneal mid-stromal nerve length and branching were initially higher in the 60D to 75D group and returned to control levels by day 135. A similar trend was observed in CD within zones 0 to 2 and 2 to 6 and in the hexagonal cells (HEX) ratio in endothelial cells, whereas ET remained consistent. Notably, these changes did not affect the efficacy, safety, or predictability of post-recovery SMILE surgery.

Conclusions

SARS-CoV-2 induces temporal alterations in corneal stromal morphology and function post-recovery. These findings provided a theoretical basis for corneal health and refractive surgery management in the post-COVID-19 milieu.

SARS-CoV-2-Related Olfactory Dysfunction: Autopsy Findings, Histopathology, and Evaluation of Viral RNA and ACE2 Expression in Olfactory Bulbs

BACKGROUND

The COVID-19 pandemic has been a health emergency with a significant impact on the world due to its high infectiousness. The disease, primarily identified in the lower respiratory tract, develops with numerous clinical symptoms affecting multiple organs and displays a clinical finding of anosmia. Several authors have investigated the pathogenetic mechanisms of the olfactory disturbances caused by SARS-CoV-2 infection, proposing different hypotheses and showing contradictory results. Since uncertainties remain about possible virus neurotropism and direct damage to the olfactory bulb, we investigated the expression of SARS-CoV-2 as well as ACE2 receptor transcripts in autoptic lung and olfactory bulb tissues, with respect to the histopathological features.

METHODS

Twenty-five COVID-19 olfactory bulbs and lung tissues were randomly collected from 200 initial autopsies performed during the COVID-19 pandemic. Routine diagnosis was based on clinical and radiological findings and were confirmed with post-mortem swabs. Real-time RT-PCR for SARS-CoV-2 and ACE2 receptor RNA was carried out on autoptic FFPE lung and olfactory bulb tissues. Histological staining was performed on tissue specimens and compared with the molecular data.

RESULTS

While real-time RT-PCR for SARS-CoV-2 was positive in 23 out of 25 lung samples, the viral RNA expression was absent in olfactory bulbs. ACE2-receptor RNA was present in all tissues examined, being highly expressed in lung samples than olfactory bulbs.

CONCLUSIONS

Our finding suggests that COVID-19 anosmia is not only due to neurotropism and the direct action of SARS-CoV-2 entering the olfactory bulb. The mechanism of SARS-CoV-2 neuropathogenesis in the olfactory bulb requires a better elucidation and further research studies to mitigate the olfactory bulb damage associated with virus action.

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.

Examining the Influence of COVID-19 Infection and Pandemic Restrictions on the Risk of Corneal Transplant Rejection or Failure: A Multicenter Study

PURPOSE

The purpose of this study was to evaluate two aims. The first was whether patients with a history of keratoplasty who developed COVID-19 were at a higher risk of corneal graft rejection or failure. The second was examining whether patients who underwent a new keratoplasty during the first 2 years of the pandemic from 2020-2022 were at a higher risk of the same outcomes compared to those undergoing keratoplasty from 2017-2019 before the pandemic.

METHODS

A multicenter research network, TriNetX, was used to query for keratoplasty patients with or without a COVID-19 between January 2020 and July 2022. Additionally, the database was also queried to identify new keratoplasties performed from January 2020-July 2022 and compare it to keratoplasties performed during a similar pre-pandemic interval between 2017-2019. 1:1 Propensity Score Matching was utilized to adjust for confounders. Graft complication of either a rejection or failure was assessed within 120 day follow-up using the Cox proportional hazard model and survival analysis.

RESULTS

A total of 21,991 patients with any keratoplasty history were identified from January 2020-July 2022, of which 8.8% were diagnosed with COVID-19. Matching revealed two balanced cohorts of 1,927 patients where no significant difference in risk of corneal graft rejection or failure among groups ((aHR [95% CI] = 0.76 [0.43,1.34]; p = .244)). Comparing first-time keratoplasties performed in a pandemic period of January 2020-July 2022 to a corresponding pre-pandemic interval from 2017-2019 also similarly revealed no differences in graft rejection or failure in matched analysis (aHR = 0.937[0.75, 1.17], p = .339).

CONCLUSIONS

This study found no significant increase in the risk of graft rejection or failure in patients with a prior keratoplasty history following COVID-19 diagnosis nor in any patients who had a new keratoplasty done during 2020-2022 when compared to a similar pre-pandemic interval.

Emerging Pathogenic Viral Infections of the Eye

Global health security threats and the public health impact resulting from emerging infectious diseases including the ongoing COVID-19 pandemic and recent Ebola virus disease outbreaks continuously emphasize the need for a comprehensive approach to preparedness, management of disease outbreaks, and health sequelae associated with emergent pathogens. A spectrum of associated ophthalmic manifestations, along with the potential persistence of emerging viral pathogens in ocular tissues, highlight the importance of an ophthalmic approach to contributing to efforts in the response to public health emergencies from disease outbreaks. This article summarizes the ophthalmic and systemic findings, epidemiology, and therapeutics for emerging viral pathogens identified by the World Health Organization as high-priority pathogens with epidemic potential.

Orbital inflammation following COVID-19 vaccination: A case series and literature review

PURPOSE

The purpose of the study was to report three cases of orbital inflammation following administration of the COVID-19 vaccination, manifesting as Tolosa-Hunt syndrome (THS) and orbital myositis.

METHOD

A retrospective case series and literature review of patients who developed orbital inflammation following a COVID-19 vaccination.

RESULTS

One patient presented with Tolosa-Hunt syndrome (THS) 14 days following her third (booster) COVID-19 vaccination, one patient developed orbital myositis 10 days following his first COVID-19 vaccination and one patient developed recurrent orbital myositis 1 and 7 days following her second and fourth COVID-19 vaccination. All patients received the Comirnaty vaccine (Pfizer-BioNTech). A thorough systemic autoimmune disease workup in both patients was unremarkable. Two patients had a prior history of orbital inflammation, with previous involvement of other different orbital structures. Characteristic MRI features for each pathology were observed, supporting the clinical presentation of THS and orbital myositis. There was complete resolution of THS following corticosteroids, with no recurrence at 2 months. Meanwhile, one case of orbital myositis self-resolved at 2 months without use of systemic corticosteroids, while the other patient with orbital myositis required treatment with intra-orbital steroid injections and oral corticosteroids.

CONCLUSION

Orbital inflammation has been recognised as a rare adverse effect following COVID-19 vaccination. We present a case series of THS and orbital myositis as varied presentations of this entity.

DrugRep-KG: Toward Learning a Unified Latent Space for Drug Repurposing Using Knowledge Graphs

Drug repurposing or repositioning (DR) refers to finding new therapeutic applications for existing drugs. Current computational DR methods face data representation and negative data sampling challenges. Although retrospective studies attempt to operate various representations, it is a crucial step for an accurate prediction to aggregate these features and bring the associations between drugs and diseases into a unified latent space. In addition, the number of unknown associations between drugs and diseases, which is considered negative data, is much higher than the number of known associations, or positive data, leading to an imbalanced dataset. In this regard, we propose the DrugRep-KG method, which applies a knowledge graph embedding approach for representing drugs and diseases, to address these challenges. Despite the typical DR methods that consider all unknown drug-disease associations as negative data, we select a subset of unknown associations, provided the disease occurs because of an adverse reaction to a drug. DrugRep-KG has been evaluated based on different settings and achieves an AUC-ROC (area under the receiver operating characteristic curve) of 90.83% and an AUC-PR (area under the precision-recall curve) of 90.10%, which are higher than in previous works. Besides, we checked the performance of our framework in finding potential drugs for coronavirus infection and skin-related diseases: contact dermatitis and atopic eczema. DrugRep-KG predicted beclomethasone for contact dermatitis, and fluorometholone, clocortolone, fluocinonide, and beclomethasone for atopic eczema, all of which have previously been proven to be effective in other studies. Fluorometholone for contact dermatitis is a novel suggestion by DrugRep-KG that should be validated experimentally. DrugRep-KG also predicted the associations between COVID-19 and potential treatments suggested by DrugBank, in addition to new drug candidates provided with experimental evidence. The data and code underlying this article are available at https://github.com/CBRC-lab/DrugRep-KG.

Bilateral Acute Iris Transillumination (BAIT): A Rare Syndrome Possibly Associated with COVID-19 and Moxifloxacin Use. A Report of 2 Cases

Bilateral acute iris transillumination (BAIT) is a rare clinical entity, presumed to be associated with preceding upper respiratory tract infection and/or use of certain antibiotics, marked by bilateral acute loss of iris pigment epithelium with pigment dispersion in the anterior chamber and trabecular meshwork, which can cause elevated intraocular pressure and glaucoma, and with iris transillumination and sphincter paralysis which lead to photophobia and blurry vision. We report the first two cases of BAIT in our center which both had a history of preceding COVID-19 (coronavirus disease 2019) and moxifloxacin use. With more awareness, ophthalmologists might diagnose more cases, and thus gain more information regarding the link between COVID-19 and BAIT, which might be underdiagnosed since it is rare or easily misdiagnosed as some more common diseases with similar features.

Central Retinal Vein Occlusion in a Young Woman with Diabetes and Hypertension after mRNA-Based COVID-19 Vaccination-A Case Report and Brief Review of the Literature

A 25-year-old female with diabetes and hypertension presented with progressive painless blurred vision in her left eye ten days after she received her third dose of the SARS-CoV-2 mRNA vaccine BNT162b2 (Pfizer-BioNTech). The clinical examination confirmed the diagnosis of Central Retinal Vein Occlusion (CRVO) complicated with macular edema. Three doses of anti-vascular endothelial growth factor (VEGF) were injected intravitreally. Visual acuity was improved from 20/100 to 20/30, but recurrence was noted at 6 months. Several cases of retinal vein occlusion (RVO) after COVID-19 vaccination have been reported. However, the present case is the youngest female individual documented to have CRVO after SARS-CoV-2 vaccination. This case demonstrates that the macular edema might be recurrent in patients with risk factors for CRVO who receive SARS-CoV-2 vaccination, suggesting the need for careful consideration of the treatment strategy and close follow-up. Although the definite pathogenesis still needs to be carefully determined, this report highlights the possible association between RVO and mRNA-based COVID-19 vaccination, even in young individuals.

Central Retinal Artery Occlusion in Rhino-Orbital-Cerebral Mucormycosis: An Inflammatory-Prothrombotic State

PURPOSE

The aim was to evaluate patient profiles of rhino-orbital-cerebral mucormycosis (ROCM) cases with central retinal artery occlusion (CRAO) postcoronavirus disease 2019.

DESIGN

A nonrandomized retrospective case-control study.

METHODS

The ROCM cases presenting with CRAO were compared with a control ROCM group without CRAO at a tertiary care center. Demography, systemic status, clinical features, histopathology, imaging, and blood profile were assessed for any specific risk factors.

RESULTS

A total of 12 patients were seen in the CRAO group and 16 in the non-CRAO group. The male-to-female ratio was 3:1 with a mean age of 49.5 years. In the CRAO group, 75% had diabetes mellitus with mean hemoglobin A1c of 9.03%, and 66.7% had received steroid treatment. All cases were histopathologically confirmed positive for mucor. There was a significant difference in mean D-dimer and serum ferritin between the 2 groups, with higher level in the CRAO group. All patients with CRAO had light perception-negative vision, with total ophthalmoplegia and proptosis seen in 66.7% of cases. Four patients had orbital apex involvement, 5 had cavernous sinus involvement, and 8 had intracranial involvement in the CRAO group.

CONCLUSIONS

Inflammatory markers D-dimer and serum ferritin were significantly associated with CRAO, suggestive of hyperinflammatory and hypercoagulable state. A high index of suspicion should be maintained in cases with elevated markers and prophylactic anticoagulants can be started to prevent CRAO in a subset of patients.

The effect of COVID-19 pandemic and wearing face masks on ophthalmology practice: What is known so far? A narrative review

Face masks, along with other preventive measures, can help slow the spread of COVID-19. Despite the positive effect of the mask in combating the virus, it has some negative effects on the human body that must be followed up on and reduced. In this study, we discuss the impact of wearing face masks on the eye and the common issues associated with using them. The literature search was conducted using electronic databases such as PubMed and Google Scholar. Only articles published in English were included. A total of 39 relevant articles were deemed eligible. After the duplicate articles were removed, the titles and abstracts of 20 papers underwent full-text screening. The review comprised both prospective and retrospective investigations, case reports, and a series of reporting ocular symptoms following the use of face masks. The COVID-19 pandemic affected ophthalmology practices in managing patients. New factors must be considered, especially when dealing with anti-VEGF injections, such as the risk of endophthalmitis, tests and symptoms of patients with glaucoma, and the emerging symptoms associated with the COVID-19 vaccination. The use of face masks and breathing aids seemed to influence the tear film.

Ocular Trauma During COVID-19 Pandemic: A Systematic Review and Meta-analysis

PURPOSE

This study aimed to summarize the latest literature on the trends and incidence of ocular trauma during the COVID-19 pandemic.

DESIGN

Systematic review and meta-analysis.

METHODS

A systematic literature search was conducted to identify the relevant literature. The search period was between January 1, 2020, and September 20, 2021. The incidence of overall and various types of ocular trauma during the COVID-19 pandemic and the control period was analyzed. The data from different studies were pooled. The odds ratio (OR) and 95% confidence interval (CI) were calculated.

RESULTS

A total of 32 articles were included. After pooling the data from all included studies, the incidence of total and pediatric ocular trauma during the COVID-19 pandemic was 67.7% and 54.3% of those in the control period, respectively. However, the proportion of ocular trauma in eye emergency visits increased during the pandemic (OR, 95% CI: 1.46, 1.04-2.06). The proportion of domestic ocular trauma increased (OR, 95% CI: 3.42, 1.01-11.62), while ocular trauma related to sports and outdoor activities and occupational ocular trauma decreased (OR, 95% CI: 0.64, 0.09-4.29 and 0.18, 0.10-0.33, respectively). It was also reported that chemical injury caused by alcohol-based sanitizers, photokeratitis caused by ultraviolet lamps, and mechanical eye injury caused by masks increased during the COVID-19 pandemic.

CONCLUSIONS

There was a reduction in overall eye injuries and substantial differences in the spectrum of ocular trauma during the COVID-19 pandemic. Proper health education and supervision should be strengthened to prevent ocular injuries related to COVID-19 preventive interventions.

Acute corneal allograft rejection following SARS-CoV-2 vaccination-A systematic review

All documented cases of acute corneal allograft rejection following SARS-CoV-2 vaccination were examined, to characterize possible risk factors and graft outcomes. Comprehensive search (4 electronic databases: PubMed, CENTRAL, ClinicalTrials.gov, Google Scholar, plus manual search in articles' reference lists) until March 1st 2022 to identify studies reporting acute corneal allograft rejection following SARS-CoV-2 vaccination; study protocol was developed in line with PRISMA statement. We analysed demographics, allograft type, rejection prophylaxis regime at the time of vaccination, transplantation-to-vaccination time (G-Vt), vaccination-to-immune reaction onset time (V-Rt), management, best-corrected visual acuity before and after rejection, and graft survival. Of 169 titles/abstracts screened, 16 studies (n  = 36 eyes) met the inclusion criteria. Fourteen eyes (38.9%) had received >1 graft, and 11.1% of cases had history of immune reactions; 52.9% of cases occurred after the first dose. Median (P25-P75) G-Vt was 48 (10-78) months; median V-Rt was 9 (7-14) days. In eyes with resolved rejection, median time-to-resolution was 3 (1-4) weeks. Four eyes (11.1%) had partial resolution of corneal decompensation, and 5 grafts (13.9%) failed. Acute corneal allograft rejection after SARS-CoV-2 vaccination is a rare event, but may occur any time post-keratoplasty. Early recognition and prompt, aggressive treatment is warranted to optimize vision and graft survival. Well-known risk factors for rejection may be confounding factors, including the high proportion of cases with a history of previous grafts and the rejection prophylaxis regimes at the time of vaccination. Increasing immunosuppressants in the peri-vaccination period may decrease the risk of immune reactions, especially in high-risk cases.

Bilateral and Multiple Central Serous Chorioretinopathy Following COVID-19 Infection: A Case Report and Literature Review

Central serous chorioretinopathy (CSCR) following coronavirus disease 2019 (COVID-19) infection is rare. We describe an adult patient who survived a COVID-19 infection and received intravenous and oral corticosteroid treatment for three weeks. He presented three weeks post COVID-19 infection with central visual loss in both eyes for six days. Fundus examination showed multiple localized serous retinal detachments in both eyes. Optical coherence tomography (OCT) of the macula confirmed the presence of multiple areas of serous retinal detachment and pigment epithelial detachment. The patient was treated with topical non-steroidal anti-inflammatory eye drops and regained full visual recovery after three months. Corticosteroid treatment for COVID-19 and psychological stress induced by the disease are potential risk factors for the development of CSCR. Physicians should be aware of this side effect, as an early referral to an ophthalmologist for treatment is essential.

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.