Ocular and Systemic Complications of COVID-19: Impact on Patients and Healthcare

ENDOGENOUS FUNGAL ENDOPHTHALMITIS AFTER COVID-19 INFECTION: CASE REPORT AND REVIEW OF LITERATURE

PURPOSE

The purpose of this study was to describe a case of endogenous endophthalmitis (EE) after severe COVID-19 disease, review patient outcomes with EE after COVID-19 infection, and review evidence regarding risk factors for developing EE.

METHODS

This is a review of health records, imaging, intravitreal injection, and pars plana vitrectomy for bilateral fungal EE after severe COVID-19 disease, and is a literature review on outcomes in EE after COVID-19 disease.

RESULTS

Sixty-three year-old man with diabetes and hypertension was admitted to hospital for severe COVID-19 disease for 3 months. His stay required intensive care unit admission, intubation, high-dose corticosteroids, tocilizumab, and was complicated by bacteremia, empyema, and fungal esophagitis. He developed floaters and bilateral vision loss (visual acuity 20/40 in the right eye, counting fingers in the left eye) with vitritis 2.5 months into his stay that did not respond to intravitreal voriconazole. Pars plana vitrectomy was performed for both eyes, resulting in visual acuity of 20/40 in the right eye, 20/30 in the left eye. Vitreous cultures were positive for Candida albicans . Endogenous endophthalmitis after COVID-19 disease has been reported in 22 patients to date, and outcomes are poor, with 40%+ of eyes legally blind (20/200 or worse). Although influenced by availability of imaging modalities and degree of training of the evaluating physician, misdiagnosis can affect ¼ of cases, delaying treatment. Age, male sex, and diabetes increase the risk of severe COVID-19, which requires prolonged hospitalization, invasive catheterization, and immunosuppression, which in turn increases the risk of nosocomial infection.

CONCLUSION

Low threshold for suspecting EE in patients presenting with floaters and decreased vision after severe COVID-19 disease is necessary to ensure prompt recognition and treatment.

The Implications of SARS-CoV-2 Infection in a Series of Neuro-Ophthalmological Manifestations-Case Series and Literature Review

The global pandemic impact of the COVID-19 infection included clinical manifestations that affected several organs and systems, with various neuro-ophthalmological manifestations associated with the infection. These are rare and occur either secondary to the presence of the virus or by an autoimmune mechanism secondary to viral antigens. The manifestations are atypical, being present even in the absence of the systemic symptoms typical of a SARS-CoV-2 infection. In this article, we introduce a series of three clinical cases with neuro-ophthalmological manifestations associated with COVID infection that were shown in Ophthalmology Clinic of St. Spiridon Emergency Hospital. Case 1 is that of a 45-year-old male patient with no personal history of general pathology or ophthalmology, with binocular diplopia, painful red eyes, and lacrimal hypersecretion with a sudden onset of about 4 days. Based on the evaluations, a positive diagnosis of orbital cellulitis in both eyes is made. Case 2 is that of a 52-year-old female patient with general PPA (personal pathological antecedents) of SARS-CoV-2 infection 1 month prior to presentation with decreased visual acuity in the right eye and a positive central scotoma, preceded by photopsia and vertigo with balance disorders. The diagnosis is made at the right eye for retrobulbar optic neuritis and post-SARS-CoV-2 infection status. The last clinical case is that of a 55-year-old male patient known to have high blood pressure (HBP) with a sudden, painless decrease in VARE approximately 3 weeks post-SARS-CoV-2 immunization (Pfizer vaccine first dose). The diagnosis is made after consulting all the RE results for central retinal vein thrombosis. Conclusions: Although the cases were quickly and efficiently investigated and the treatment was administered adequately by a multidisciplinary team (cases 1 and 3), the evolution was not favorable in all three situations. Atypical neuro-ophthalmological manifestations can also be present in the absence of systemic symptoms typical of SARS-CoV-2 infection.

Case of acute vision loss after injectable remdesivir with anticoagulants and overdose of antibiotics: A late report

A woman reported decreased vision in the right eye since hospitalization for COVID-19. Vision in the right eye was 6/18 and in the left eye was counting fingers. Her left eye had cataract and right eye was pseudophakic with earlier documented good recovery. In the right eye, she had branch retinal vein occlusion (BRVO) with macular edema documented on optical coherence tomography (OCT). It was suspected that it might be an ocular manifestation of COVID-19 which had not been reported and had worsened. An overdose of antibiotics or remdesivir might also be responsible for the same. She was advised anti-VEGF injections and was kept under treatment.

COVID-19 and ocular complications: A review of ocular manifestations, diagnostic tools, and prevention strategies

Background

The novel severe acute respiratory syndrome coronavins 2 (SARS-CoV-2) led to the severe Corona Virus Disease 2019 (COVID-19) outbreak that started in December 2019 in China and caused enormous health and economic problems worldwide. Over time, SARS-CoV-2 has demonstrated the capacity for mutation. As the most prevalent new coronavirus variety worldwide, the Omicron variant has supplanted the Delta variant. The COVID-19 primarily damages the immune system and the lungs, but it can also harm other organs secondarily, depending on the patients' co-existing conditions.

Main Text

COVID-19 is associated with ophthalmic manifestations such as conjunctival congestion, tear overflow, and conjunctival edema, with the majority of eye complications occurring in patients with severe infection. The virus may make a patient more susceptible to thrombotic conditions that affect venous and arterial circulation. Meanwhile, it can lead to efferent complications and mucormycosis which is more common in patients with diabetes or who have critical or severe SARS-CoV-2 infection. Significantly, there are a number of ocular side effects following the COVID-19 vaccination, such as herpetic keratitis and facial nerve palsy, which have been reported. These side effects may be caused by the vaccinations' propensity to trigger autoimmune symptoms or thromboembolic events. At present, large-scale nucleic acid testing mainly relies on nasopharyngeal swabs and throat swabs. Tear samples and conjunctival swabs may be helpful samples for the diagnosis of ocular SARS-CoV-2 infection. The eye could be a new route of infection, and finding ways such as effective environmental disinfection, scientific administrative control management, qualified personal protection and other measures to protect the eyes could further reduce the risk of infection.

Conclusions

This review aims to sum up the ocular complications of COVID-19, the possible pathogenesis, and preventive strategies to protect ophthalmology practitioners and patients by reviewing the currently available literature on the topic.

Case Report: Acquired Brown Syndrome after COVID-19 Vaccination

SIGNIFICANCE

Brown syndrome, or superior oblique tendon sheath syndrome, is characterized by limitation of elevation on adduction. The disorder is thought to involve the trochlea/superior oblique tendon complex through traumatic, surgical, and inflammatory mechanisms. It could be an indication of multiple underlying immunological or rheumatological disorders.

PURPOSE

This study aimed to report an unusual strabismus after receiving the first dose of a live attenuated coronavirus disease 2019 (COVID-19) vaccine.

CASE REPORT

A 31-year-old female patient presented with painful vertical diplopia and tenderness of the left trochlear area 3 days after the first dose of COVID-19 vaccination. She had a compensatory chin elevation and face turn to the right, as well as a left 10-prism-diopter hypotropia in the primary position, which increased to 15 prism diopters in the right gaze and disappeared in the left gaze. Ocular motility revealed the limitation of elevation on adduction. The patient denied any history of ocular trauma and was consequently investigated for dysthyroid disease and various immunological and rheumatological disorders, which were excluded. A Hess chart was obtained to document the motility disorder.

CONCLUSIONS

We report a case of acquired Brown syndrome in a 31-year-old otherwise healthy woman shortly after COVID-19 vaccination. It is possible that the patient may have developed trochleitis and/or superior oblique tenosynovitis brought on by cross-reacting antibodies generated by the immune response to the vaccine. In the age of the widest vaccination campaign in human history, it is highly likely that we will continue to observe many unexpected potential adverse effects of these vaccines in our clinical practice.

Genome-Wide Pleiotropy Study Identifies Association of PDGFB with Age-Related Macular Degeneration and COVID-19 Infection Outcomes

Age-related macular degeneration (AMD) has been implicated as a risk factor for severe consequences from COVID-19. We evaluated the genetic architecture shared between AMD and COVID-19 (critical illness, hospitalization, and infections) using analyses of genetic correlations and pleiotropy (i.e., cross-phenotype meta-analysis) of AMD (n = 33,976) and COVID-19 (n ≥ 1,388,342) and subsequent analyses including expression quantitative trait locus (eQTL), differential gene expression, and Mendelian randomization (MR). We observed a significant genetic correlation between AMD and COVID-19 infection (r_G = 0.10, p = 0.02) and identified novel genome-wide significant associations near PDGFB (best SNP: rs130651; p = 2.4 × 10^-8) in the pleiotropy analysis of the two diseases. The disease-risk allele of rs130651 was significantly associated with increased gene expression levels of PDGFB in multiple tissues (best eQTL p = 1.8 × 10^-11 in whole blood) and immune cells (best eQTL p = 7.1 × 10^-20 in T-cells). PDGFB expression was observed to be higher in AMD cases than AMD controls {fold change (FC) = 1.02; p = 0.067}, as well as in the peak COVID-19 symptom stage (11-20 days after the symptom onset) compared to early/progressive stage (0-10 days) among COVID-19 patients over age 40 (FC = 2.17; p = 0.03) and age 50 (FC = 2.15; p = 0.04). Our MR analysis found that the liability of AMD risk derived from complement system dysfunction {OR (95% CI); hospitalization = 1.02 (1.01-1.03), infection = 1.02 (1.01-1.03) and increased levels of serum cytokine PDGF-BB {β (95% CI); critical illness = 0.07 (0.02-0.11)} are significantly associated with COVID-19 outcomes. Our study demonstrated that the liability of AMD is associated with an increased risk of COVID-19, and PDGFB may be responsible for the severe COVID-19 outcomes among AMD patients.

Acute retinal necrosis in a patient on immunosuppressive treatment for COVID-19 pneumonia: a case report

BACKGROUND

Patients with coronavirus disease 2019 (COVID-19) occasionally develop ocular complications. We report a case of acute retinal necrosis (ARN) caused by Epstein-Barr Virus (EBV) that developed in a patient who had severe acute respiratory syndrome due to SARS-CoV-2 infection.

CASE PRESENTATION

A 68-year-old woman complained of floaters and blurred vision in her right eye as she was receiving systemic prednisolone for COVID-19 pneumonia under isolation in our hospital. The patient visited an ophthalmologist following her discharge from the hospital and after the 2 weeks of isolation had ended. At the initial examination, her best-corrected visual acuity (BCVA) was 20/100 in the right eye, and the eye showed moderate anterior segment inflammation and vitreous opacities. Treatment was initiated with topical 0.1% betamethasone and 1.5% levofloxacin. After 1 month, the inflammation in the right eye decreased and her BCVA improved to 20/40. However, on day 48 from her initial visit, the inflammation in her right eye worsened and her BCVA decreased to 20/2000 by day 80. Pars plana vitrectomy with silicone oil tamponade was performed to remove the vitreous opacities, and expanded white exudates peripherally and retinal vessels with white sheathing suggestive of acute retinal necrosis (ARN) were seen intraoperatively. Analysis of the vitreous sample revealed EBV positivity on polymerase chain reaction. The patient was diagnosed with EBV-associated ARN and treated with systemic steroids and valaciclovir. The ocular inflammation gradually decreased, and she was discharged from the hospital. However, a week later, the inflammation in the right eye markedly worsened. Despite another course of steroids, the inflammation worsened, resulting in total retinal detachment and absolute glaucoma. Because of the severe pain, the right eye was enucleated.

CONCLUSIONS

Clinicians should be aware that COVID-19 and immunosuppressive treatment can reactivate EBV in the eye.

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.

Ocular Complications after COVID-19 Vaccination, Vaccine Adverse Event Reporting System

In December 2020, the U.S. Food and Drug Administration licensed COVID-19 vaccines for emergency use authorization. We investigated the ocular adverse event reports in patients reported to the Vaccine Adverse Event Reporting System (VAERS) following vaccination against COVID-19. We searched the VAERS database for U.S. reports among persons who received COVID-19 vaccines between December 2020 and December 2021. Our goal was to analyze and quantify the ocular adverse events submitted to VAERS to provide clinicians and researchers with a broader view of these ocular side effects. During the analysis period, VAERS received 55,313 adverse event reports and, after data cleaning, 6688 reports met the inclusion criteria. Note that 2229 (33.33%) adverse events were classified as cases of eyelid swelling, ocular hyperemia and conjunctivitis, 1785 (26.69%) as blurred vision and 1322 (19.77%) as visual impairment. Females accounted for 73.8% of adverse event reports and the age group between 40 and 59 years had the most frequent adverse events. A higher proportion of these adverse events reported to VAERS was linked with the Janssen and Moderna COVID-19 vaccines. At the time of vaccination, a high proportion of patients reported conditions like allergies, hypertension, diabetes, thyroid disease, vascular and other autoimmune diseases. A review of these data suggests a possible association between COVID-19 vaccines and ocular adverse events. Physicians are cautioned not only to be aware of this potential problem, but to check any underlying patient conditions, and to carefully document in VAERS within a few weeks of vaccination. Future COVID-19 vaccine safety studies in healthy subjects would help clarify the vaccine’s safety profile.