Ocular MRI Findings in Patients with Severe COVID-19: A Retrospective Multicenter Observational Study

Disorders with Ophthalmic and Thoracic Involvement

A variety of systemic conditions involve the thorax and the eyes. While subtle or nonspecific eye symptoms can be the initial clinical manifestation of some disorders, there can be additional manifestations in the thorax that lead to a specific diagnosis and affect patient outcomes. For instance, the initial clinical manifestation of Sjögren syndrome is dry eye or xerophthalmia; however, the presence of Sjögren lung disease represents a fourfold increase in mortality. Likewise, patients with acute sarcoidosis can initially present with pain and redness of the eye from uveitis in addition to fever and parotitis. Nearly 90% of patients with sarcoidosis have thoracic involvement, and the ophthalmologic symptoms can precede the thoracic symptoms by several years in some cases. Furthermore, a diagnosis made in one system can result in the screening of other organs as well as prompt genetic evaluation and examination of family members, such as in the setting of Marfan syndrome or Ehlers-Danlos syndrome. Multimodality imaging, particularly CT and MRI, plays a vital role in identification and characterization of these conditions. While it is helpful for ophthalmologists to be knowledgeable about these conditions and their associations so that they can order the pertinent radiologic studies, it is also important for radiologists to use the clues from ophthalmologic examination in addition to imaging findings to suggest a specific diagnosis. Systemic conditions with thoracic and ophthalmologic manifestations can be categorized as infectious, inflammatory, autoimmune, neoplastic, or hereditary in origin. The authors describe a spectrum of these conditions based on their underlying cause. ©RSNA, 2024.

Portable color retinography findings in COVID-19 patients admitted to the ward

Retinal lesions, including cotton-wool exudates, microbleeds, vascular occlusions and vasculitis, occur in a minority of Coronavirus Disease-19 (COVID-19) patients. Retinal assessments using retinography can help document these lesions. The objective of this work was to identify retinal changes in patients admitted to the ward with a positive Real Time Quantitative Polymerase Chain Reaction (RT-qPCR) exam for COVID-19. A cross-sectional, observational study was carried out of patients with mild and moderate symptoms admitted to the Hospital de Base in São José do Rio Preto. The Eyer® portable retinal camera (Phelcom® Technologies) was used to evaluate 30 male and 21 female patients. The ages ranged from 21 to 83 years (mean: 47 years). Systemic arterial hypertension was identified in 21 (41.2 %) and diabetes mellitus in 12 (23.5 %) patients. Six (11.7 %) reported worsening visual acuity, however, none of these patients had ocular findings to justify this complaint. Ten patients (19.6 %) had intraretinal hemorrhages; one (1.9 %) had cotton-wool exudates and seven (13.7 %) had dilations of veins. Thirteen patients (25.4 %) had vascular tortuosity and six (11.7 %) had pathological arteriovenous crossings. Portable retinography is useful to evaluate patients admitted to isolation wards due to COVID-19. It is important to remember that some of the patients investigated had comorbidities like diabetic maculopathy and systemic arterial hypertension. Hence, some care should be taken in attributing these observations uniquely to COVID-19 infection.

Central retinal artery occlusion in a young child affected by COVID-19: a first case report

BACKGROUND

Central retinal artery occlusion (CRAO) is an ophthalmic emergency, and its etiology is generally ascribed to vessel occlusion by a thrombus or embolus, eventually due to a hypercoagulable state. CRAO occurrence is described even in the pediatric population, but its incidence is very rare. SARS-CoV-2 infection has a multitude of presentations, and almost any organ may be involved including the ocular district. Cases of CRAO in patients affected by COVID-19 are reported in the literature in the adult population, but not in the pediatric one.

CASE PRESENTATION

We describe the case of a six-year-old otherwise healthy girl, who presented a sudden and complete bilateral vision loss after a one-day fever. All the clinical, ophthalmological, laboratory and instrumental investigations led to the diagnosis of a right CRAO and the suspicion of a contralateral posterior optic nerve affection. These manifestations could not be ascribed to any etiological condition apart from the documented ongoing mild SARS-CoV-2 infection. Treatment with anticoagulants and steroids was tried but the visual outcome was poor during the one-month hospitalization and at the last follow-up.

CONCLUSIONS

To the best of our knowledge, this is the first report of CRAO in the course of SARS-CoV-2 infection in the pediatric age. In our review of the literature, we found few cases of CRAO in adults with COVID-19; we highlighted differences in anamnestic, clinical, and interventional aspects and therefore we tried to summarize the state of the art on this topic to facilitate further studies. Even if rare, the prognosis of CRAO is poor and the thrombolytic treatment could be effective only if rapidly administered, so the disease suspicion should be high in a patient with sudden vision loss, also in pediatric age.

Virtual reality for assessing stereopsis performance and eye characteristics in Post-COVID

In 2019, we faced a pandemic due to the coronavirus disease (COVID-19), with millions of confirmed cases and reported deaths. Even in recovered patients, symptoms can be persistent over weeks, termed Post-COVID. In addition to common symptoms of fatigue, muscle weakness, and cognitive impairments, visual impairments have been reported. Automatic classification of COVID and Post-COVID is researched based on blood samples and radiation-based procedures, among others. However, a symptom-oriented assessment for visual impairments is still missing. Thus, we propose a Virtual Reality environment in which stereoscopic stimuli are displayed to test the patient's stereopsis performance. While performing the visual tasks, the eyes' gaze and pupil diameter are recorded. We collected data from 15 controls and 20 Post-COVID patients in a study. Therefrom, we extracted features of three main data groups, stereopsis performance, pupil diameter, and gaze behavior, and trained various classifiers. The Random Forest classifier achieved the best result with 71% accuracy. The recorded data support the classification result showing worse stereopsis performance and eye movement alterations in Post-COVID. There are limitations in the study design, comprising a small sample size and the use of an eye tracking system.

Evaluation of the retina with optical coherence tomography angiography (OCTA) in patients with coronavirus (COVID-19) infection

PURPOSE

The goal of this study is to compare the optical coherence tomography angiography (OCTA) findings in Coronavirus (COVID-19) positive adult and pediatric patients with those of healthy volunteers with the same demographic characteristics.

METHODS

The right eye of 157 adults infected with covid, 168 healthy adult volunteers, 40 children (6-18 years of age) infected with covid, and 44 healthy children (6-18 years of age) were included in this prospective study. All participants underwent ophthalmological examination and OCTA. The OCTA findings were evaluated.

RESULTS

Deep nasal density (DND), deep inferior density (DID), and deep parafoveal density (DPD) were significantly lower in the pediatric covid-affected group (PCAG) than in the pediatric healthy control group (PHCG) (P=0.034, P=0.029, P=0.022 respectively). On the other hand, radial peripapillary capillary vessel density (RPCVD) intra-disc measurements were significantly higher in the PCAG compared to the PHCG (P=0.025). There was no significant difference between the OCTA measurements of the adult covid-affected group (ACAG) and the adult healthy control group (AHCG).

CONCLUSION

In our study, significant differences were found in OCTA measurements between the covid group and the healthy control group in children. Retinal microvascular changes may occur in patients with covid infection, and these patients might be followed for long-term retinal changes.

Ocular manifestations of COVID-19

COVID-19 is a disease caused by a SARS-CoV-2 viral infection, a disease that was first detected in December 2019 in Wuhan, Hubei Province, China. COVID-19, formerly known as 2019 Novel Coronavirus (2019-nCoV) respiratory disease, was officially named COVID-19 by the World Health Organization (WHO) in February 2020. By 25 May 2021, there were 33,579,116 confirmed cases with 599,109 COVID-19 deaths worldwide. The purpose of this review article is to provide an update on what is currently known about COVID-19 ocular symptoms in adults, the elderly, and children in the literature. Finally, this article will review the eye protection precautions that should be implemented in our clinics. To assess the current literature, PubMed was searched from December 2019 to 25 May 2021. Randomized trials, observational studies, case series or case reports, letters of research, and letters to editors were selected for confirmed cases of COVID-19. According to current scientific literature since the outbreak in December 2019, 205 articles have been published. Conjunctivitis, conjunctival hyperemia, and chemosis have been reported in adults with COVID-19. There have been few studies on children and elderly patients, and further research in these age groups is needed. Finally, wearing eye protection when seeing patients on a daily basis during the pandemic is essential.

COVID-19 and Retinal Degenerative Diseases: Promising link “Kaempferol”

Coronavirus disease (COVID-19) outbreak has caused unprecedented global disruption since 2020. Approximately 238 million people are affected worldwide where the elderly succumb to mortality. Post-COVID syndrome and its side effects have popped up with several health hazards, such as macular degeneration and vision loss. It thus necessitates better medical care and management of our dietary practices. Natural flavonoids have been included in traditional medicine and have also been used safely against COVID-19 and several other diseases. Kaempferol is an essential flavonoid that has been demonstrated to influence several vital cellular signaling pathways involved in apoptosis, angiogenesis, inflammation, and autophagy. In this review, we emphasize the plausible regulatory effects of Kaempferol on hallmarks of COVID-19 and macular degeneration.

Ocular Manifestations in Patients with Coronavirus Disease 2019 (COVID-19): A Real World Multicenter Observational Study in Egypt

Background:

The aim of the work was to evaluate the ocular manifestations in the patients with COVID-19 and its role in the prediction of the course and the outcome of the disease.

Methods:

This retrospective study was conducted at two tertiary referral COVID-19 isolation hospitals in two major university hospitals in Egypt. Two hundred and twenty-eight patients were enrolled in the study. The medical records of patients who had clinically confirmed COVID-19 between 1/5/2020 to 15/7/2020 were retrospectively reviewed. Data were collected from patient charts, including age, sex, accommodation, ocular manifestations, fever, headache, cough, dyspnea, anosmia, cyanosis, abdominal pain, anorexia, liver, kidney, cardiac manifestations, CT, X-ray finding, blood tests, and outcome of the disease.

Results:

Thirty-four patients with ocular manifestation were finally enrolled in the study with a mean age of 42.1 years; 20 patients (58.8%) were men. The incidence of ocular manifestation was 14.9% (34/228). All patients with ocular manifestations had conjunctivitis (redness, epiphora, foreign body sensation), which had been treated and resolved completely within 10 days in all patients without any permanent ocular damage. There was a trend between the presence of ocular manifestations and the associated milder disease course, although this trend was not statistically significant.

Conclusion:

Ophthalmic manifestation is common in patients with COVID-19 and it occurs more frequently in patients with mild to moderate form of COVID-19, but it could not predict the patient’s mortality.

Ocular Manifestations in Patients with Coronavirus Disease 2019 (COVID-19): A Real World Multicenter Observational Study in Egypt

Background:

The aim of the work was to evaluate the ocular manifestations in the patients with COVID-19 and its role in the prediction of the course and the outcome of the disease.

Methods:

This retrospective study was conducted at two tertiary referral COVID-19 isolation hospitals in two major university hospitals in Egypt. Two hundred and twenty-eight patients were enrolled in the study. The medical records of patients who had clinically confirmed COVID-19 between 1/5/2020 to 15/7/2020 were retrospectively reviewed. Data were collected from patient charts, including age, sex, accommodation, ocular manifestations, fever, headache, cough, dyspnea, anosmia, cyanosis, abdominal pain, anorexia, liver, kidney, cardiac manifestations, CT, X-ray finding, blood tests, and outcome of the disease.

Results:

Thirty-four patients with ocular manifestation were finally enrolled in the study with a mean age of 42.1 years; 20 patients (58.8%) were men. The incidence of ocular manifestation was 14.9% (34/228). All patients with ocular manifestations had conjunctivitis (redness, epiphora, foreign body sensation), which had been treated and resolved completely within 10 days in all patients without any permanent ocular damage. There was a trend between the presence of ocular manifestations and the associated milder disease course, although this trend was not statistically significant.

Conclusion:

Ophthalmic manifestation is common in patients with COVID-19 and it occurs more frequently in patients with mild to moderate form of COVID-19, but it could not predict the patient’s mortality.

Neuroradiologic Imaging of Neurologic and Neuro-Ophthalmic Complications of Coronavirus-19 Infection

BACKGROUND

To review the literature and provide a summary of COVID-19-related neurologic and neuro-ophthalmic complications.

METHODS

The currently available literature was reviewed on PubMed and Google Scholar using the following keywords for searches: CNS, Neuro-Ophthalmology, COVID-19, SARS-CoV-2, coronavirus, optic neuritis, pseudotumor cerebri, Acute Disseminated Encephalomyelitis, posterior reversible encephalopathy syndrome (PRES), meningitis, encephalitis, acute necrotizing hemorrhagic encephalopathy, and Guillain-Barré and Miller Fisher syndromes.

RESULTS

Neuroradiologic findings of neurologic and neuro-ophthalmologic complications in relationship to COVID-19 infection were reviewed. Afferent visual pathway-related disorders with relevant imaging manifestations included fundus nodules on MRI, papilledema and pseudotumor cerebri syndrome, optic neuritis, Acute Disseminated Encephalomyelitis, vascular injury with thromboembolism and infarct, leukoencephalopathy, gray matter hypoxic injury, hemorrhage, infectious meningitis/encephalitis, acute necrotizing hemorrhagic encephalopathy, and PRES. Efferent visual pathway-related complications with relevant imaging manifestations were also reviewed, including orbital abnormalities, cranial neuropathy, Guillain-Barré and Miller Fisher syndromes, and nystagmus and other eye movement abnormalities related to rhombencephalitis.

CONCLUSION

COVID-19 can cause central and peripheral nervous system disease, including along both the afferent and efferent components of visual axis. Manifestations of disease and long-term sequela continue to be studied and described. Familiarity with the wide variety of neurologic, ophthalmic, and neuroradiologic presentations can promote prompt and appropriate treatment and continue building a framework to understand the underlying mechanism of disease.

COVID-19 as a new risk factor for the development of acute vascular diseases of the optic nerve and retina

The new coronavirus disease (COVID-19) is a viral respiratory infection accompanied by systemic endotheliitis. COVID-19 patients usually encounter changes related to hypercoagulability, hypofibrinolysis, and increased intravascular platelet aggregation. There is also a vascular wall thromboresistance decrease and impaired vasomotor function, which significantly increase the risk of thromboembolic complications. Currently, pathogenic aspects of the relationship between COVID-19 and vascular and inflammatory conditions of the optic nerve and retina are actively investigated. One of the triggers of impaired blood flow in ocular vessels may be a perfusion pressure decrease, observed in the acute period of the infectious process. This is related to both COVID-19 clinical course features and to resuscitation specificity as well. Secondary autoimmune inflammation is being considered as a mechanism of damage to the vascular wall in the post-infectious period. In this publication, possible pathogenic links of these diseases are considered for the first time in a specific context of the example of ischemic optic neuropathy associated with coronavirus infection.

Abnormal MRI findings of the orbital or visual pathways in patients with severe COVID-19: Observations from the French multicenter COVID-19 cohort

OBJECTIVES

COVID-19 is a multisystemic disease. Ophthalmological abnormalities are relatively rare among COVID-19-infected patients. The aim of our study was to report orbital and visual pathways MRI findings in a nationwide multicenter cohort of patients with severe COVID-19.

METHODS

This IRB-approved retrospective multi-center study included participants presenting with severe COVID-19, who underwent brain MRI from March 4th to May 1st 2020. Two neuroradiologists ("blinded"), blinded to all data, individually analyzed morphological MRIs focusing on the orbits and the visual pathways. A second consensus reading session was performed in the case of disagreement between both readers. Clinical and ophthalmological data were compared to MRI findings. Descriptive statistical analysis and interobserver agreement for MRI reading using non-weighted Cohen kappa statistics were performed.

RESULTS

129 participants (43 [33%] women and 86 [67%] men, mean age 63 ± 14 years) were included in the study. 17/129 (13%) patients had abnormal MRI findings of the orbit or visual pathways. 11/17 (65%) patients had a FLAIR-WI hyperintense optic disc. 6/17 (35%) patients had abnormal signal of at least one of the visual pathway structures: 6/6 (100%) of the optic nerve, 1/6 (17%) of the optic chiasm, 2/6 (33%) of the optic tract and 1/6 (17%) of the optic radiations.

CONCLUSIONS

Our study showed that a substantial number of patients with severe COVID-19 presented with abnormal MRI findings of the orbit or visual pathways, which might lead to potentially severe visual impairment.

Review of COVID-19, part 2: Musculoskeletal and neuroimaging manifestations including vascular involvement of the aorta and extremities

The coronavirus disease 2019 (COVID-19) pandemic caused by the novel severe acute respiratory syndrome coronavirus (SARS-CoV-2) has affected almost every country in the world resulting in severe morbidity, mortality and economic hardship, altering the landscape of healthcare forever. Its devastating and most frequent thoracic and cardiac manifestations have been well reported since the start of the pandemic. Its extra-thoracic manifestations are myriad and understanding them is critical in diagnosis and disease management. The role of radiology is growing in the second wave and second year of the pandemic as the multiorgan manifestations of COVID-19 continue to unfold. Musculoskeletal, neurologic and vascular disease processes account for a significant number of COVID-19 complications and understanding their frequency, clinical sequelae and imaging manifestations is vital in guiding management and improving overall survival. The authors aim to provide a comprehensive overview of the pathophysiology of the virus along with a detailed and systematic imaging review of the extra-thoracic manifestation of COVID-19. In Part I, abdominal manifestations of COVID-19 in adults and multisystem inflammatory syndrome in children will be reviewed. In Part II, manifestations of COVID-19 in the musculoskeletal, central nervous and vascular systems will be reviewed.

Imaging in the COVID-19 era: Lessons learned during a pandemic

The first year of the coronavirus disease 2019 (COVID-19) pandemic has been a year of unprecedented changes, scientific breakthroughs, and controversies. The radiology community has not been spared from the challenges imposed on global healthcare systems. Radiology has played a crucial part in tackling this pandemic, either by demonstrating the manifestations of the virus and guiding patient management, or by safely handling the patients and mitigating transmission within the hospital. Major modifications involving all aspects of daily radiology practice have occurred as a result of the pandemic, including workflow alterations, volume reductions, and strict infection control strategies. Despite the ongoing challenges, considerable knowledge has been gained that will guide future innovations. The aim of this review is to provide the latest evidence on the role of imaging in the diagnosis of the multifaceted manifestations of COVID-19, and to discuss the implications of the pandemic on radiology departments globally, including infection control strategies and delays in cancer screening. Lastly, the promising contribution of artificial intelligence in the COVID-19 pandemic is explored.