Ocular Manifestations of COVID-19 (SARS-CoV-2): A Critical Review of Current Literature

Ocular A-to-I RNA editing signatures associated with SARS-CoV-2 infection

Ophthalmic manifestations have recently been observed in acute and post-acute complications of COVID-19 caused by SARS-CoV-2 infection. Our precious study has shown that host RNA editing is linked to RNA viral infection, yet ocular adenosine to inosine (A-to-I) RNA editing during SARS-CoV-2 infection remains uninvestigated in COVID-19. Herein we used an epitranscriptomic pipeline to analyze 37 samples and investigate A-to-I editing associated with SARS-CoV-2 infection, in five ocular tissue types including the conjunctiva, limbus, cornea, sclera, and retinal organoids. Our results revealed dramatically altered A-to-I RNA editing across the five ocular tissues. Notably, the transcriptome-wide average level of RNA editing was increased in the cornea but generally decreased in the other four ocular tissues. Functional enrichment analysis showed that differential RNA editing (DRE) was mainly in genes related to ubiquitin-dependent protein catabolic process, transcriptional regulation, and RNA splicing. In addition to tissue-specific RNA editing found in each tissue, common RNA editing was observed across different tissues, especially in the innate antiviral immune gene MAVS and the E3 ubiquitin-protein ligase MDM2. Analysis in retinal organoids further revealed highly dynamic RNA editing alterations over time during SARS-CoV-2 infection. Our study thus suggested the potential role played by RNA editing in ophthalmic manifestations of COVID-19, and highlighted its potential transcriptome impact, especially on innate immunity.

Who Is the Intermediate Host of RNA Viruses? A Study Focusing on SARS-CoV-2 and Poliovirus

The COVID-19 pandemic has sparked a surge in research on microbiology and virology, shedding light on overlooked aspects such as the infection of bacteria by RNA virions in the animal microbiome. Studies reveal a decrease in beneficial gut bacteria during COVID-19, indicating a significant interaction between SARS-CoV-2 and the human microbiome. However, determining the origins of the virus remains complex, with observed phenomena such as species jumps adding layers to the narrative. Prokaryotic cells play a crucial role in the disease's pathogenesis and transmission. Analyzing previous studies highlights intricate interactions from clinical manifestations to the use of the nitrogen isotope test. Drawing parallels with the history of the Poliovirus underscores the need to prioritize investigations into prokaryotic cells hosting RNA viruses.

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.

Post-COVID-19 endogenous endophthalmitis case series and review of literature

PURPOSE

To describe a series of post-coronavirus disease 2019 (COVID-19) endogenous endophthalmitis (EE) patients from a multispecialty tertiary hospital in North India.

METHODS

A retrospective chart review including all consecutive cases with EE following confirmed COVID-19 disease from July 2020 to June 2021.

RESULTS

Seven eyes of four patients (three female and one male) were included. Two patients had confirmed bilateral fungal (Aspergillus sp.) EE and two patients had presumed fungal EE (one bilateral and one unilateral). Three of these four patients received systemic steroids as part of COVID-19 treatment previously. Five eyes were managed with initial intravitreal injection (IVI), followed by pars plana vitrectomy (PPV), and two eyes were managed with only IVI. All patients received systemic antifungal agents. Intraocular inflammation resolved in all eyes with treatment. One patient of EE also developed voriconazole-induced transient visual hallucination, which resolved on discontinuing the medication.

CONCLUSION

This case series represents a series of EE cases following COVID-19 disease or its sequelae or as a result of prior treatment for COVID-19. Ophthalmologists and physicians must be vigilant about these complications and initiate prompt management at the earliest.

Neuro-Ophthalmic Adverse Events of COVID-19 Infection and Vaccines: A Nationwide Cohort Study

Purpose

To evaluate the association of COVID-19 infection and vaccination with neuro-ophthalmic adverse events.

Methods

In this nationwide population-based retrospective cohort study, 8,498,353 patients were classified into three groups: control, COVID-19 infection, and COVID-19 vaccination. We conducted separate analyses for the early phase (within 60 days) and late phases (61-180 days) to estimate the incidence rates and hazard ratio (HR) for each neuro-ophthalmic adverse event. The adverse events included in this analysis were optic neuritis, papilledema, ischemic optic neuropathy, third nerve palsy, fourth nerve palsy, sixth nerve palsy, facial palsy, nystagmus, ptosis, blepharospasm, anomalies of pupillary function, and Guillain-Barré syndrome/Miller Fisher syndrome (GBS/MFS).

Results

Neuro-ophthalmic adverse events other than ptosis and GBS/MFS exhibited no significant increase after COVID-19, and their incidence was extremely low. The incidence rate of ptosis in both phases was significantly higher in patients administered COVID-19 vaccination (HR = 1.65 in the early phase and HR = 2.02 in the late phase) than in the control group. Additionally, BNT162b2 conferred a lower ptosis risk than ChAdOx1. GBS/MFS had a significantly higher incidence rate in the early phase (HR = 5.97) in patients with COVID-19 infection than in the control group.

Conclusions

Ptosis was associated with COVID-19 vaccination, particularly with the ChAdOx1 vaccine, while GBS/MFS was associated with COVID-19 infection. In contrast, no association was found between other neuro-ophthalmic adverse events and COVID-19 infection or vaccination. These results may provide helpful insights for diagnosing and treating the neuro-ophthalmological adverse events after COVID-19.

Assessing the Risk of Stroke in the Elderly in the Context of Long-COVID, Followed Through the Lens of Family Medicine

BACKGROUND/AIM

Patients infected with COVID-19 may experience a range of acute and chronic neurological disorders. While severe neurological complications like strokes and seizures were less common during the acute or post-COVID period, the long-term effects of COVID-19, known as long COVID, have received limited attention. This study aimed to examine the lasting consequences of SARS-CoV-2 infection and establish potential connections with related diseases.

PATIENTS AND METHODS

We followed a group of 157 patients for one year, predominantly from urban areas (61.8%), divided into three groups based on the presence of associated diseases that pose health risks: the control (43 patients), low-risk (67 patients), and high-risk (47 patients) groups.

RESULTS

We observed an inverse relationship between oxygen saturation and erythrocyte sedimentation rate, as well as a direct relationship between varicose disease and dyslipidemia, and gastrointestinal disease. Additionally, we noticed a less significant improvement in oxygen saturation and increased prevalence of psychoanxiety disorders in individuals undergoing anticoagulant treatment.

CONCLUSION

The impact of long COVID and its secondary effects, which persist for an extended period and are influenced by associated diseases, can be effectively monitored and addressed by primary care physicians. These findings can serve as a basis for developing more efficient approaches to managing the long-term consequences of COVID-19.

Endogenous endophthalmitis in post-COVID-19 patients: a case report

Ocular involvement in coronavirus disease 2019 (COVID-19) can be due to direct viral invasion or indirectly due to an immunosuppressed state. Prolonged hospitalization also makes them susceptible to various secondary infections. The purpose of this case report is to report two rare cases of endogenous endophthalmitis (EE) in COVID-19 recovered patients.

Case presentation

Two patients who were hospitalized and received treatment for COVID-19 pneumonia with remdesivir and systemic steroids presented with decreased vision. The first case had a severe anterior chamber reaction with a hypopyon and dense exudates in the vitreous. The second case had cells and flare in the anterior chamber and exudates in the vitreous. They were diagnosed with EE and underwent a diagnostic vitreous tap followed by pars plana vitrectomy and intravitreal antibiotic and steroid. The culture of vitreous fluid was negative for any bacteria and fungus in both cases. However, the first case demonstrated Escherichia coli in urine culture. The follow-up visual acuity was no perception of light and only perception of light in the first and second case, respectively.

Clinical discussion

Severe COVID-19 patients who are hospitalized, receive systemic steroid and have associated comorbidities like diabetes mellitus are at high risk of EE.

Conclusion

Delay in diagnosis and appropriate treatment in these patients leads to poor visual outcome.

Arteritic Anterior Ischemic Optic Neuropathy (AAION) Associated with COVID-19 Infection: A Case Report and Review of the Literature

Anterior ischemic optic neuropathy (AION) is the most frequent cause of acute optic nerve damage in the elderly, usually causing acute, unilateral, and painless permanent visual loss. Arteritic anterior ischemic optic neuropathy (AAION) is a result of endothelial cell inflammation and the subsequent thrombosis and occlusion in the blood-supplying arteries of the optic nerve head. AAION accounts only for 5-10% of all AION cases that are associated with vasculitis which usually takes place in the course of a giant cell arteritis (GCA). In this paper, we report a case of AAION following a COVID-19 respiratory infection. Although it is uncertain whether SARS-CoV-2 infection triggered the AAION or was coincidental, the possible association of the events is concerning.

Tomographic Findings in the Retina of Unvaccinated Patients with COVID Pneumonia: Prospective Longitudinal Study

There is no definitive evidence on the extent of SARS-CoV-2's effect on the retina. This study aims to determine if the natural history of SARS-CoV-2 infection affects tomographic findings in the retina of patients with COVID-19 pneumonia. This is a prospective cohort study of patients hospitalized with COVID-19 pneumonia. The patients underwent ophthalmological explorations and optical coherence tomography during the acute phase of the infection and at a follow-up 12 weeks later. The primary outcomes were the central retinal thickness and central choroidal thickness, which were compared longitudinally and with non-COVID-19 historical controls. No statistically relevant differences were observed in the longitudinal analysis of the thickness of the central retina (p = 0.056), central choroid (p = 0.99), retinal nerve fiber layer (p = 0.21), or ganglion cell layer (p = 0.32). Patients with acute COVID-19 pneumonia showed significantly greater central retinal thickness than non-COVID controls (p = 0.006). In conclusion, tomographic measures of the retina and choroid are not influenced by the phase of COVID-19 infection and remain stable during 12 weeks. The central retinal thickness may increase in the acute phase of COVID-19 pneumonia, but more epidemiological studies using optical coherence tomography in the early stages of the disease are needed.

Ophthalmic manifestations in patients recovered from COVID-19 in Mexico

INTRODUCTION AND OBJECTIVES

Although the ophthalmic manifestations appear to be associated with the coronavirus disease 2019 (COVID-19), there is not enough evidence. Hence, the aim of this study was to determine the various types and frequency of ophthalmic manifestations in patients recovered from SARS-CoV-2 infection in Mexico.

MATERIAL AND METHODS

This retrospective, observational and descriptive study included all patients recovered from SARS-CoV-2 infection attending the tertiary level hospital of Mexican Social Security Institute (IMSS) from June 2020 to June 2022. During the hospital admission of patients, the demographic data such age, name, gender was recorded. Ophthalmologic examination was performed under torchlight by an ophthalmologist in the Department of Ophthalmology from IMSS. Data was compiled and statistically analyzed using Fisher's exact test and Spearman correlation.

RESULTS

A total of 3,081 SARS-CoV-2-positive patients were recorded, of which 318 (10.32%) met the inclusion criteria. Of them, 21 (6.60%) had ophthalmic manifestations and the female-to-male ratio was 1.6:1. The mean age (±SD) was 47.95 ± 15.27 years and the median (interquartile range) time from the diagnosis of COVID-19, as defined by positive SARS-CoV-2 RT-PCR testing, to detection of the ophthalmic manifestation was 31 (142) days. The most common ocular manifestation was orbital mucormycosis (23.80%). Interestingly, the presence of ophthalmic manifestations was not associated with severe COVID-19 (p = 0.665).

CONCLUSIONS

The ophthalmic manifestations are infrequent in patients recovered from severe COVID-19. Nevertheless, further large sample studies are needed to confirm these findings.

Choroidal and Retinal Vascular Findings in Patients with COVID-19 Complicated with Pneumonia: Widefield Imaging

Purpose: The purpose of this study was to analyze choroidal and retinal vascular alterations of both the macula and midperiphery areas in patients hospitalized for COVID-19 infection complicated with pneumonia within 30 days from discharge. Methods: A total of 46 eyes of 23 subjects with a history of symptomatic COVID-19 infection and recent hospitalization for pneumonia were enrolled in this observational study. Patients had not been previously vaccinated against COVID-19. A group of patients homogenous for age and sex was enrolled as controls. Microvascular retinal and choroidal features of the enrolled patients were studied with widefield optical coherence tomography angiography (OCT-A). Perfusion parameters in terms of the vessel density (VD) of the superficial capillary plexus (SCP) and deep capillary plexus (DCP) and the choroidal vascularity index (CVI) on enhanced depth imaging (EDI) mode OCT scans were analyzed. Results: Our cohort of patients showed a trend of reduction in VD, significantly in the SCP VD of the superior and inferior midperiphery sectors, whereas the CVI did not show significant differences between the cases and controls. Moreover, a positive correlation between CVI and vessel density in the deep capillary plexus in the macular area (VD-DCP-MAC) was found. Conclusion: The systemic disease due to COVID-19 can also involve the retina and choroid with multiple mechanisms: ischemic and inflammatory. Our study showed changes in perfusion occurring in the eyes of patients with a recent hospitalization for COVID-19 complicated with pneumonia and without any possible ocular effect due to the vaccines. There is still the need to better comprise how long COVID-19 actually affects vascular changes in the eye.

Potential of using facial thermal imaging in patient triage of flu-like syndrome during the COVID-19 pandemic crisis

The screening of flu-like syndrome is difficult due to nonspecific symptoms or even oligosymptomatic presentation and became even more complex during the Covid-19 pandemic. However, an efficient screening tool plays an important role in the control of highly contagious diseases, allowing more efficient medical-epidemiological approaches and rational management of global health resources. Infrared thermography is a technique sensitive to small alterations in the skin temperature which may be related to early signs of inflammation and thus being relevant in the detection of infectious diseases. Thus, the objective of this study was to evaluate the potential of facial thermal profiles as a risk evaluator of symptoms and signs of SARs diseases, using COVID-19 as background disease. A total of 136 patients were inquired about the most common symptoms of COVID-19 infection and were submitted to an infrared image scanning, where the temperatures of 10 parameters from different regions of the face were captured. We used RT-qPCR as the ground truth to compare with the thermal parameters, in order to evaluate the performance of infrared imaging in COVID-19 screening. Only 16% of infected patients had fever at the hospital admission, and most infrared thermal variables presented values of temperature significantly higher in infected patients. The maximum eye temperature (MaxE) showed the highest predictive value at a cut-off of >35.9°C (sn = 71.87%, sp = 86.11%, LR+ = 5.18, LR- = 0.33, AUC = 0.850, p < 0.001). Our predictive model reached an accuracy of 86% for disease detection, indicating that facial infrared thermal scanning, based on the combination of different facial regions and the thermal profile of the face, has potential to act as a more accurate diagnostic support method for early COVID-19 screening, when compared to classical infrared methods, based on a single spot with the maximum skin temperature of the face.

Update on Corneal Confocal Microscopy Imaging

In vivo corneal confocal microscopy (IVCM) is a non-invasive ophthalmic imaging technique that provides images of the cornea at the cellular level. Despite the uses in ocular surface pathologies, in the last decades IVCM has been used to provide more knowledge in refractive surgery wound healing, in neuropathies diagnosis, etc. The observation of the corneal cells, both normal and inflammatory, and the possibility of quantification of the corneal nerve density with manual or automated tools, makes IVCM have a significant potential to improve the diagnosis and prognosis in several systemic and corneal conditions.

Ocular symptoms in COVID-19 infection: a survey study

BACKGROUND

Coronavirus disease 2019 (COVID-19) systemic symptoms and sequelae have been studied extensively, but less is known about the characterization, duration, and long-term sequelae of ocular symptoms associated with COVID-19 infection. The purpose of this study was to analyze the frequency, spectrum, and duration of ocular symptoms in participants with COVID-19 infection treated in inpatient and outpatient settings.

METHODS

A retrospective electronic survey was distributed to NIH employees and the public who reported testing positive for SARS-CoV-2. The anonymous survey collected information on demographics, past ocular history, systemic COVID-19 symptoms, and ocular symptoms.

RESULTS

A total of 229 (21.9% male and 78.1% female, mean age 42.5 ± 13.9) survey responses were included. Ocular symptoms were reported by 165 participants with a mean of 2.31 ± 2.42 symptoms. The most commonly reported ocular symptoms were light sensitivity (31.0%), itchy eyes (24.9%), tearing (24.9%), eye redness (24.5%), and eye pain (24.5%). Participants with ocular symptoms had a higher number of systemic symptoms compared to participants without ocular symptoms (mean 9.17 ± 4.19 vs 6.22 ± 3.63; OR: 1.21; 95% CI: 1.11 - 1.32; p < 0.001). Ocular symptoms were more common in those who reported a past ocular history compared to those who did not (81.8% vs 67.1%; OR: 2.17; 95% CI: 1.08 - 4.37; p = 0.03). Additionally, the onset of ocular symptoms occurred most frequently at the same time as systemic symptoms (47.5%), and 21.8% reported symptoms lasting ≥ 14 days.

CONCLUSIONS

Ocular surface-related symptoms are the most frequent ocular manifestations, and systemic disease severity is associated with the presence of ocular symptoms. Additionally, our results show that ocular symptoms can persist post-COVID-19 infection. Further work is needed to better understand ocular symptoms in COVID-19 and long-term sequelae.

Analysis of macular structure in age-related cataract patients with different antibody levels of severe acute respiratory syndrome coronavirus-2 vaccine

Objective

To analyze the macular structure of age-related cataract (ARC) patients with different antibody levels after COVID-19 vaccine injection, in order to obtain the effect of COVID-19 vaccine on the macular structure, and speculate whether the COVID-19 vaccine has adverse effects on the macular structure.

Methods

This retrospective study is conducted to analysis on the status of COVID-19 vaccine and the thickness of different layers at different positions in the macular area of ARC patients. In the age, sex and eye axial length matched population, in the un-injection, no-antibody, IgM and IgG positive groups after vaccination, the choroid, ganglion cell complex, nerve fiber layer and retinal thickness at different positions of ETDRS zoning in the macular area were discussed.

Results

A total of 164 patients (164 eyes) were included in the analysis. There were 63 males and 101 females. The average age was 65.99 ± 8.43 years. There was no significant difference in age and sex among the groups (p>0.05). The average axial length of 164 eyes was 23.56 ± 1.46mm, and no significant difference between the groups (p>0.05). Non parametric test and ANOVA test for the thickness of choroid, retina, ganglion cell complex and retinal nerve fiber layer in each division of ETDRS showed no significant difference in the four groups of un-injection, no-antibody, IgM and IgG (p>0.05). There was no correlation between the antibody concentration and the thickness of macular structure (p>0.05).

Conclusion

There was no significant difference in the thickness of choroid, retina, ganglion cell complex and retinal fiber layer in different macular areas after COVID-19 vaccine injection. There was no linear correlation between the thickness of choroid, retina, ganglion cell complex and retinal fiber layer and the antibody concentration produced after COVID-19 vaccine injection. It suggests that the injection of COVID-19 vaccine might have no significant effect on the macular structure of eye.

Ocular effects caused by viral infections and corresponding vaccines: An overview of varicella zoster virus, measles virus, influenza viruses, hepatitis B virus, and SARS-CoV-2

Many viral infections can affect vision and the visual system. Vaccination to prevent diseases is commonplace today, acting by stimulating an immune response without developing the pathology. It involves the production of persisting antibodies against the pathogen and the activation of T cells. Certain diseases have already been eradicated by rigorous vaccination campaigns, while others are hoped to be eliminated soon. Vaccines currently available on the market are largely safe, even if they can rarely cause some adverse effects, such as ocular complications. Analyzing existing literature, we aimed to compare the pathological effects on the eye due to the most common viral infections [in particular varicella zoster virus (VZV), measles virus, influenza viruses, hepatitis B virus, and SARS-CoV-2] with the possible ocular adverse effects of their relative vaccines, in order to establish a risk-benefit relationship from an ophthalmological point of view.

Endothelial Dysfunction in COVID-19: Potential Mechanisms and Possible Therapeutic Options

SARS-CoV-2, a novel coronavirus found in Wuhan (China) at the end of 2019, is the etiological agent of the current pandemic that is a heterogeneous disease, named coronavirus disease 2019 (COVID-19). SARS-CoV-2 affects primarily the lungs, but it can induce multi-organ involvement such as acute myocardial injury, myocarditis, thromboembolic eventsandrenal failure. Hypertension, chronic kidney disease, diabetes mellitus and obesity increase the risk of severe complications of COVID-19. There is no certain explanation for this systemic COVID-19 involvement, but it could be related to endothelial dysfunction, due to direct (endothelial cells are infected by the virus) and indirect damage (systemic inflammation) factors. Angiotensin-converting enzyme 2 (ACE2), expressed in human endothelium, has a fundamental role in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In fact, ACE2 is used as a receptor by SARS-CoV-2, leading to the downregulation of these receptors on endothelial cells; once inside, this virus reduces the integrity of endothelial tissue, with exposure of prothrombotic molecules, platelet adhesion, activation of coagulation cascades and, consequently, vascular damage. Systemic microangiopathy and thromboembolism can lead to multi-organ failure with an elevated risk of death. Considering the crucial role of the immunological response and endothelial damage in developing the severe form of COVID-19, in this review, we will attempt to clarify the underlying pathophysiological mechanisms.

Evaluation of Retinal Microvascular Impairment after COVID-19 and its Clinical Correlates Using Optical Coherence Tomography Angiography

Objectives

Retinal vascular complications have been described in patients with coronavirus disease 2019 (COVID-19). This study aimed to analyze retinal microvascular changes and their correlations with clinical findings.

Materials and Methods

This case-controlled study was conducted in a university hospital. The right eyes of 52 otherwise healthy patients recovered from COVID-19 and 42 healthy controls were examined with optical coherence tomography angiography. Mann-Whitney U test was used to compare vessel density (VD) and foveal avascular zone (FAZ) parameters. Associations with treatment choices, pneumonia, and laboratory findings were analyzed.

Results

Twenty-nine patients (56%) and 18 healthy controls (43%) were men. Mean age of the COVID-19 group was 39.00±13.04 years. Twenty-two patients had pneumonia, 18 (35%) received hydroxychloroquine (HCQ), 17 (33%) received HCQ plus low-molecular-weight heparin (LMWH), and 10 (19%) received favipiravir. The patient group had lower parafoveal VD in the superficial capillary plexus (SCP) and lower parafoveal VD and perifoveal VD in the deep capillary plexus (DCP) than controls (p=0.003, p=0.004, p=0.001). FAZ area did not differ significantly (p=0.953). Perifoveal VD in the DCP was also significantly lower in the HCQ+LMWH group than the HCQ group (p=0.020) and in the presence of pneumonia (p=0.040). C-reactive protein (CRP) and ferritin levels were negatively correlated with perifoveal VD in the DCP (r=-0.445, p=0.023; r=-0.451, p=0.040). Ferritin was also negatively correlated with parafoveal VD in the SCP (r=-0.532, p=0.013).

Conclusion

Parafoveal and perifoveal VD was found to be lower in the COVID-19 group. Presence of pneumonia, need for LMWH prophylaxis, and levels of CRP and ferritin were found to be negatively associated with retinal VD. Large-scale studies are needed to evaluate the clinical importance.

Laboratory and Point-of-Care Testing for COVID-19: A Review of Recent Developments

With the emergence of Coronavirus infection called COVID-19, testing is essential for containment and mitigation purposes. In a pandemic, control is essential to limit the spread of any virus. Initially, contact tracing was not available which ultimately led to the 2020 pandemic. However, with the development of COVID-19 rapid testing, the rate of infections has lessened and has allowed for some return to normalcy. In this review, we discuss the various antibody, antigens, and molecular tests that have been given emergency authorization (EA) from the Food and Drug Administration (FDA). Moreover, we will discuss the various point-of-care tests as well as the specificity and sensitivity that are associated with each testing kit. With appropriate testing, we can be aware of how the virus spreads and how prevalent it remains.

Impact of the COVID-19 Pandemic on the Incidence and Characteristics of Culture-Positive Microbial Keratitis at a Tertiary Eye Hospital in the UK

Purpose

The COVID-19 pandemic has led to drastic changes to the daily lives of those living in the United Kingdom. We hypothesized that the effect of the imposed lockdown on both behaviour and social interaction has the potential to influence the characteristics of microbial keratitis presenting locally to Manchester Royal Eye Hospital — a major tertiary eye centre in the UK.

Methods

We conducted a retrospective case-note review of all positive corneal scrape cultures identified by our local microbiology laboratory during the year since the announcement of lockdown measures in the UK (23 March 2020 to 23 March 2021). Culture results were compared with previously collated, published “baseline” data from prior to the onset of the COVID-19 pandemic (2004–2019). Statistical analysis was undertaken, predominantly looking at the incidence of microbial keratitis and the variety of cultured pathogens.

Results

A total of 6243 corneal scrape results were reviewed. Comparison of data between the COVID-19 pandemic and subsequent lockdown did not show a significant change in the incidence of culture-positive microbial keratitis: mean annual positive samples during 2004–2019 were 128 (35%) vs 91 (29%) during lockdown (P=0.096). No statistically significant shifts in the incidence of organism subtypes — fungi, acanthamoeba, Gram-positive bacteria, or Gram negative bacteria — were identified (P=0.196, 1, 0.366, and 0.087, respectively).

Conclusion

Contrary to our hypothesis, our results suggest that the COVID-19 pandemic did not alter the incidence or characteristics of microbial keratitis presenting to Manchester Royal Eye Hospital in the year following the implementation of lockdown measures in the UK.

Unilateral Acute Central Serous Chorioretinopathy with Inactivated Coronavirus Disease 2019 Vaccination: A Case Report and Review of Literature

Purpose

To report unilateral acute-onset central serous chorioretinopathy (CSC) following vaccination with inactivated coronavirus disease 2019 (COVID-19) vaccine in a healthy patient.

Methods

Case report and review of literature.

Results

A 39-year-old male was referred with sudden-onset, painless, unilateral blurred vision in the right eye. His first dose of the Sinopharm vaccine was injected 2 days before. A complete ocular examination revealed central subretinal fluid (SRF) accumulation in favor of CSC in the right eye. Systemic workup disclosed no previous COVID-19 infection or any systemic involvement. After 3 weeks, SRF decreased remarkably without treatment.

Conclusions

It is proposed that CSC development can be an ocular adverse effect of COVID-19 vaccination, although it is infrequent. Ophthalmologists should be aware of the possible association between COVID-19 vaccination and ocular adverse effects, but vaccination is the best effectual measure against COVID-19.

Retinal Findings of Hospitalized Neonates Recovered from COVID-19 Infection: A Prospective, Observational, Descriptive Study

PURPOSE

Coronavirus disease 2019 (COVID-19) that is caused by severe acute respiratory syndrome coronavirus 2 can cause microvascular alterations that can lead to irreversible complications in multiple tissues and organs. Detrimental effects of COVID-19 on retinal structure have recently been reported in adult population. However, literature data about neonatal population is very scarce. Thus, we aimed to assess possible retinal changes of neonates recovered from COVID-19 infection in this prospective, observational, descriptive study.

METHODS

The neonates recovered from COVID-19 infection were included to the study between 01 September 2020 and 30 April 2021. Their initial ophthalmological examination was made after a negative real-time reverse transcription-polymerase chain reaction obtained and all patients were re-examined 1 month later. All examinations were performed by same retina specialist using a binocular indirect ophthalmoscopy.

RESULTS

A total of 15 neonates [9 (60%) male, 6 (40%) female, mean gestational age of 38.9 ± 0.9 weeks (ranging from 37 to 40 week)] were evaluated in the study. The mean age at the time of hospitalization was 17.5 ± 8.7 days (ranging from 2 to 29 days), and the mean duration of hospitalization was 12.5 ± 6.2 days (ranging from 4 to 27 days). Except for one patient with bilateral avascular area in Zone-III, no further retinal manifestation related to COVID-19 was found in the study.

CONCLUSION

COVID-19 infection can cause retinal damage in neonates. Therefore, these patients should be closely monitored for signs of ocular involvement.

Assessment of corneal endothelial cell morphology and anterior segment parameters in COVID-19

Background

The ocular manifestations of the 2019 novel coronavirus disease (COVID-19) vary from acute follicular, pseudomembranous, and hemorrhagic conjunctivitis to keratoconjunctivitis with subepithelial infiltrates and dendritic lesions. Similar to other respiratory viruses, such as adenoviruses, it is thought that COVID-19 may impact the cornea. However, its impact on the cornea and anterior segment parameters are currently poorly understood.

Objective

This study aims to assess the corneal endothelial cell morphology and anterior segment parameters in patients who have recovered from COVID-19.

Methods

In this cross-sectional study, the COVID-19 group comprised 34 patients who had been diagnosed with and recovered from COVID-19, while the control group comprised age- and sex-matched individuals without any systemic or ocular diseases. The endothelial cell density (ECD), coefficient of variation (CV) of cell area, hexagonal cell percentage (HEX), anterior chamber depth (ACD), central corneal thickness (CCT), horizontal anterior chamber diameter (HACD), iridocorneal angle (ICA), horizontal visible iris diameter (HVID), pupillary diameter (PD), and keratometry values (K1 and K2) were analyzed for each participant. The differences in each of these between the groups were analyzed using either an independent samples t test or a Mann-Whitney U test based on the normality of the data.

Results

Regarding corneal endothelial cell morphology, the ECDs for the COVID-19 and control groups were 2278.50 ± 186.78 cells/mm² and 2420.15 ± 222.25 cells/mm², respectively (p = 0.002). A significant increase was noted in CV values in the COVID-19 group compared with the control group (p < 0.001). The HEX values for the COVID-19 and control groups were 56.26 ± 5.75 and 61.50 ± 3.63, respectively (p < 0.001). Regarding the anterior segment parameters, no significant differences were observed between the groups (p > 0.05).

Conclusions

It was hypothesized that individuals who had recovered from COVID-19 would demonstrate a reduction in their endothelial functional preserves. A decrease in ECD and HEX and an increase in CV were observed in the individuals during their early post-recovery period from COVID-19.

COVID-19 and the Human Eye: Conjunctivitis, a Lone COVID-19 Finding - A Case-Control Study

OBJECTIVES

COVID-19 has varied clinical manifestations, from asymptomatic to severe cases, and conjunctivitis is one of them, but sometimes a lone initial symptom is found to be present. The aim of this study was to identify the prevalence of conjunctivitis as the first symptom in COVID-19 patients in a primary healthcare unit.

METHODOLOGY

A retrospective study was conducted, analyzing the presenting complains/symptoms and results of COVID-19-confirmatory tests.

RESULTS

Out of the 672 cases that were sent for RT-PCR testing, only 121 (18%) were found to be positive. Among these, 2.67% patients had both conjunctivitis and COVID-19, 77.77% patients had unilateral eye affected, while 22.22% had bilateral conjunctivitis of varying degrees. Fifteen patients diagnosed to have both acute conjunctivitis and COVID-19 presented other symptoms associated with COVID-19 infection. Three patients had only acute conjunctivitis during their entire course of COVID-19.

CONCLUSIONS

Conjunctivitis is a symptom of COVID-19 and may be the first sign of the infection, until the onset of the classical manifestations; such patients may continue to be a viral reservoir. Physicians should not miss unilateral conjunctivitis as it can be the only presenting complaint of COVID-19 during the initial phase, which might worsen if undetected and can aid in the spread of the contagion.

The enzymes in COVID-19: A review

COVID-19 brought a scientific revolution since its emergence in Wuhan, China, in December 2019. Initially, the SARS-CoV-2 virus came to attention through its effects on the respiratory system. However, its actions in many other organs also have been discovered almost daily. As enzymes are indispensable to uncountable biochemical reactions in the human body, it is not surprising that some enzymes are of relevance to COVID-19 pathophysiology. Past evidence from SARS-CoV and MERS-CoV outbreaks provided hints about the role of enzymes in SARS-CoV-2 infection. In this setting, ACE-2 is an enzyme of great importance since it is the cell entry receptor for SARS-CoV-2. Clinical data elucidate patterns of enzymatic alterations in COVID-19, which could be associated with organ damage, prognosis, and clinical complications. Further, viral mutations can create new disease behaviors, and these effects are related to the activity of enzymes. This review will discuss the main enzymes related to COVID-19, summarizing the findings on their role in viral entry mechanism, the consequences of their dysregulation, and the effects of SARS-CoV-2 mutations on them.

Detection of SARS-CoV-2-RNA in post-mortem samples of human eyes

Purpose

To detect SARS-CoV-2 RNA in post-mortem human eyes. Ocular symptoms are common in patients with COVID-19. In some cases, they can occur before the onset of respiratory and other symptoms. Accordingly, SARS-CoV-2 RNA has been detected in conjunctival samples and tear film of patients suffering from COVID-19. However, the detection and clinical relevance of intravitreal SARS-CoV-2 RNA still remain unclear due to so far contradictory reports in the literature.

Methods

In our study 20 patients with confirmed diagnosis of COVID-19 were evaluated post-mortem to assess the conjunctival and intraocular presence of SARS-CoV-2 RNA using sterile pulmonary and conjunctival swabs as well as intravitreal biopsies (IVB) via needle puncture. SARS-CoV-2 PCR and whole genome sequencing from the samples of the deceased patients were performed. Medical history and comorbidities of all subjects were recorded and analyzed for correlations with viral data.

Results

SARS-CoV-2 RNA was detected in 10 conjunctival (50%) and 6 vitreal (30%) samples. SARS-CoV-2 whole genome sequencing showed the distribution of cases largely reflecting the frequency of circulating lineages in the Munich area at the time of examination with no preponderance of specific variants. Especially there was no association between the presence of SARS-CoV-2 RNA in IVBs and infection with the variant of concern (VOC) alpha. Viral load in bronchial samples correlated positively with load in conjunctiva but not the vitreous.

Conclusion

SARS-CoV-2 RNA can be detected post mortem in conjunctival tissues and IVBs. This is relevant to the planning of ophthalmologic surgical procedures in COVID-19 patients, such as pars plana vitrectomy or corneal transplantation. Furthermore, not only during surgery but also in an outpatient setting it is important to emphasize the need for personal protection in order to avoid infection and spreading of SARS-CoV-2. Prospective studies are needed, especially to determine the clinical relevance of conjunctival and intravitreal SARS-CoV-2 detection concerning intraocular affection in active COVID-19 state and in post-COVID syndrome.

Early percutaneous tracheostomy in COVID19 patients with failed intubation: A case series

INTRODUCTION

COVID19 and pulmonary dysfunction leading to acute respiratory distress syndrome (ARDS).

CASE STUDY PRESENTATION

Herein we presented the cases of failed intubation that was replaced by early percutaneous dilational tracheostomy. The procedure is safe for the patients, doctors and clinical staff.

CONCLUSION

Additionally, we report mucormycosis after COVID19 treatment that was potentially due to immunosuppressive drugs.

Acute bilateral retrobulbar optic neuritis - An atypical sequela of COVID-19

Coronavirus disease 19 (COVID-19) and its ophthalmic manifestations have been variably portrayed. We report a case of a 56-year-old female presenting with sudden-onset vision loss associated with painful extraocular muscle movements in both eyes following COVID-19. Visual acuity was counting fingers close to face. Color perception tested was inaccurate. Ocular examination revealed sluggishly reacting pupils and an otherwise unremarkable fundus picture in both eyes, giving us an impression of bilateral retrobulbar neuritis. Magnetic resonance imaging of the brain and orbit were unremarkable, while blood investigations revealed nothing suggestive. The patient dramatically improved with steroid therapy with full visual recovery and a color vision defect. This presentation of bilateral retrobulbar neuritis as a sequela of COVID-19 is presented for its rarity.

Small fiber neuropathy in the cornea of Covid-19 patients associated with the generation of ocular surface disease

Purpose

To describe the association between Sars-CoV-2 infection and small fiber neuropathy in the cornea identified by in vivo corneal confocal microscopy.

Methods

Twenty-three patients who had overcome COVID-19 were recruited to this observational retrospective study. Forty-six uninfected volunteers were also recruited and studied as a control group. All subjects were examined under in vivo confocal microscopy to obtain images of corneal subbasal nerve fibers in order to study the presence of neuroma-like structures, axonal beadings and dendritic cells. The Ocular Surface Disease Index (OSDI) questionnaire and Schirmer tear test were used as indicators of Dry Eye Disease (DED) and ocular surface pathology.

Results

Twenty-one patients (91.31%) presented alterations of the corneal subbasal plexus and corneal tissue consistent with small fiber neuropathy. Images from healthy subjects did not indicate significant nerve fiber or corneal tissue damage. Eight patients reported increased sensations of ocular dryness after COVID-19 infection and had positive DED indicators. Beaded axons were found in 82.60% of cases, mainly in patients reporting ocular irritation symptoms. Neuroma-like images were found in 65.22% patients, more frequently in those with OSDI scores >13. Dendritic cells were found in 69.56% of patients and were more frequent in younger asymptomatic patients. The presence of morphological alterations in patients up to 10 months after recovering from Sars-CoV-2 infection points to the chronic nature of the neuropathy.

Conclusions

Sars-CoV-2 infection may be inducing small fiber neuropathy in the ocular surface, sharing symptomatology and morphological landmarks with DED and diabetic neuropathy.

[Bilateral central serous chorioretinopathy post-COVID-19]

La maladie à virus corona (COVID-19) peut provoquer de nombreuses manifestations oculaires. Nous rapportons un cas rare de choriorétinopathie séreuse centrale bilatérale, post-infection au COVID-19, chez une femme âgée de 38 ans qui s’est présentée pour un flou visuel bilatéral, 1 mois après l’infection au COVID-19. Elle avait de la fièvre, des frissons, une toux et un essoufflement avec fatigue et elle était positive au COVID-PCR. Pendant son séjour de 10 jours à l’hôpital, elle a reçu une oxygénothérapie, des antibiotiques, de l’héparine et des corticoïdes par voie intraveineuse puis relais par voie orale en ambulatoire. Après sa guérison du COVID-19, la patiente a développé une baisse progressive de l’acuité visuelle des 2 yeux : son acuité visuelle de loin corrigée était de 3/10 dans les 2 yeux, le segment antérieur était normal et le vitré était clair. L’examen du fond d’œil, complété par la tomographie en cohérence optique et l’angiographie à la fluorescéine a montré des décollements séreux rétiniens bilatéraux. L’évolution a été marquée par une amélioration de l’acuité visuelle et une régression des décollements séreux rétiniens. La choriorétinopathie séreuse centrale peut survenir après une infection au COVID-19 en raison de l’administration des corticoïdes et un contrôle ophtalmologique précoce est indispensable pour dépister au plus tôt une atteinte oculaire.

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.

Bell’s palsy after inactivated COVID-19 vaccination in a patient with history of recurrent Bell’s palsy: A case report

BACKGROUND

With rapid and extensive administration of inactivated coronavirus disease 2019 (COVID-19) vaccine to the general population in China, it is crucial for clinicians to recognize neurological complications or other side effects associated with COVID-19 vaccination.

CASE SUMMARY

Here we report the first case of Bell’s palsy after the first dose of inactivated COVID-19 vaccine in China. The patient was a 36-year-old woman with a past history of Bell’s palsy. Two days after receiving the first dose of the Sinovac Life Sciences inactivated COVID-19 vaccine, the patient developed right-side Bell’s palsy and binoculus keratoconjunctivitis. Prednisone, artificial tears and fluorometholone eye drops were applied. The patient’s symptoms began to improve by day 7 and resolved by day 54.

CONCLUSION

As mRNA COVID-19 vaccine trials reported cases of Bell’s palsy as adverse events, we should pay attention to the occurrence of Bell’s palsy after inactivated COVID-19 vaccination. A history of Bell’s palsy, rapid increase of immunoglobulin M and immunoglobin G-specific antibodies to severe acute respiratory syndrome coronavirus 2 may be risk factors for Bell‘s palsy after COVID-19 vaccination.

Retinal OCT Findings in Patients after COVID Infection

PURPOSE

The aim of this study was to assess and compare the optic nerve, retina, and retinal vessel parameters in recovered COVID-19 patients and healthy patients by using optical coherence tomography angiography (OCT-a).

METHODS

In all, 156 eyes of post-COVID-19 patients and 98 eyes of subjects from a control group were enrolled in our study. BCVA, intra ocular pressure (IOP) measurement, fundus examination, and OCT images, including macular cube, OCT-RNFL, and angio-OCT 6 × 6 mm examinations, were performed for both groups. The measurements were acquired using Swept Source OCT DRI OCT Triton. In the post-COVID-19 group, 762 OCT protocols were obtained. For statistical analysis, parameters from only one eye from each subject were taken.

RESULTS

In the measured parameters, no significant differences were observed, i.e., central macular thickness (p = 0.249); RNFL (p = 0.104); FAZ (p = 0.63); and vessel density of superficial retinal vascular plexus in central (p = 0.799), superior (p = 0.767), inferior (p = 0.526), nasal (p = 0.402), and temporal (p = 0.582) quadrants. Furthermore, a slit-lamp examination did not reveal any COVID-19-related abnormalities.

CONCLUSION

OCT examination did not detect any significant changes in morphology or morphometry of the optic nerve, retina, or the retina vessels due to COVID-19.

Knowledge and awareness-based survey of COVID-19 within the eye care profession in Nepal: Misinformation is hiding the truth

BACKGROUND

Nepal was under a severe lockdown for several months in 2020 due to the COVID-19 pandemic. There were concerns regarding misinformation circulating on social media. This study aimed to analyse the knowledge and awareness of COVID-19 amongst eye care professionals in Nepal during the first wave of the pandemic.

METHODOLOGY

We invited 600 participants from 12 ophthalmic centres across Nepal to complete a qualitative, anonymous online survey. Altogether, 25 questions (both open and closed-ended) were used. An overall performance score was calculated from the average of the 12 "Knowledge" questions for all the participants.

RESULTS

Of the 600 eye care professionals invited, 310 (51%) participated in the survey. The symptoms of COVID-19 were known to 94%, whilst only 49% of the participants were aware how the disease was transmitted, with 54% aware that anyone can be infected with SARS-CoV-2. Almost 98% of participants recognized the World Health Organization's (WHO) awareness message, but surprisingly, 41% of participants felt that consumption of hot drinks helps to destroy the virus, in contradiction to WHO information. Importantly, 95% of the participants were aware of personal protective equipment (PPE) and what the acronym stands for. Social distancing was felt to be key to limiting the disease spread; whilst 41% disagreed that PPE should be mandatory for eye care practitioners. The mean overall "Knowledge" performance score was 69.65% (SD ± 22.81).

CONCLUSION

There is still considerable scope to improve the knowledge of COVID-19 amongst ophthalmic professionals in Nepal. Opinion is also split on measures to prevent transmission, with misinformation potentially fuelling confusion. It is recommended to follow WHO and national guidelines, whilst seeking published scientific evidence behind any unofficial statements, to accurately inform one's clinical practice.

Endogenous Endophthalmitis A Complication of COVID-19 Pandemic: A Case Series

PURPOSE

To report six patients with endogenous endophthalmitis as a complication of COVID-19 infection.

METHODS

A multicentric retrospective database review of patients with a diagnosis of endogenous endophthalmitis and a history of COVID-19 infection.

RESULTS

Four of six patients were diabetics. All presented after an average duration of 40 days (Range 17-90 days) of COVID-19 infection. Two of six patients had bilateral involvement. Five of six patients had received intravenous corticosteroid for COVID-19. Two of six vitreous samples showed fungi (Candida and Bipolaris species), two showed bacteria (Staphylococcus species) and two samples were culture negative. Control of infection with good visual outcome in four out of eight eyes.

CONCLUSIONS

COVID-19 patients with a history of hospitalization and prolonged use of systemic corticosteroids and comorbidities, for example, diabetes mellitus have a high risk of endogenous endophthalmitis. A high index of clinical suspicion with timely intervention can salvage many eyes.

Retinal manifestations in patients following COVID-19 infection: A consecutive case series

Purpose

To describe retinal manifestations seen in patients associated with COVID-19 infection at a multi-specialty tertiary care hospital in Southern India.

Methods

In this retrospective chart review, all consecutive cases presenting to the Retina-Uveitis service from May 2020 to January 2021 with retinal manifestations associated with COVID-19 infection or its sequelae or as a result of treatment given for COVID-19 were included.

Results

: Of the 7 patients, 3 were female, and 4 were male. Four patients had onset of symptoms during the active phase of COVID-19 infection. Four had bilateral and three had unilateral involvement. The manifestations ranged from mild to vision threatening. Vision threatening manifestations included infections: endogenous endophthalmitis, candida retinitis and tubercular choroidal abscess and bilateral pre-foveal hemorrhages. Milder manifestations included paracentral acute middle maculopathy, central serous chorio-retinopathy and voriconazole induced visual symptoms. Final visual acuity was 6/36 or better in the four severe cases and 6/9 or better in the mild cases.

Conclusion

This study highlights the retinal manifestations associated with COVID-19 infection and its sequelae. As these patients presented with an association with COVID-19 (either during or after recovery), ophthalmologists should be vigilant and screen for such entities in case of complaints of visual symptoms or in the presence of systemic sepsis. The outcomes can be good with prompt and aggressive management.

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

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

Ocular Manifestations of Patients with Coronavirus Disease 2019: A Comprehensive Review

Apart from conjunctival involvement which is the most well-known ocular manifestation of coronavirus infectious disease 2019 (COVID-19), there are multiple reports of the involvement of other ocular structures by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We comprehensively reviewed PubMed, Scopus, Embase, and Google Scholar for available evidence regarding COVID-19 various ocular manifestations, with special focus on less known and unusual ocular findings. We then categorized the findings based on the parts of the eye which was involved. In anterior sections of the eye, the involvement of the eyelid (tarsadenitis), conjunctiva and cornea (follicular conjunctivitis, pseudomembranous conjunctivitis, and keratoconjunctivitis), episclera (nodular episcleritis), uvea (anterior uveitis) were reported. Also, third, fourth, and sixth nerve palsy, retinal vasculitis, retinal optical coherence tomography (OCT) changes (hyper-reflective lesions and increased retinal nerve fiber layer thickness [RNFLT]), optic neuritis, papillophlebitis, Miller Fisher syndrome, posterior reversible leukoencephalopathy (PRES), ophthalmic artery and central retinal artery occlusion, and polyneuritis cranialis were reported in different studies. Postmortem evaluation of COVID-19 patients detected no viral RNA in different anterior and posterior segments of the eyes. However, another study revealed a 21.4% positivity of the retinal biopsies of dead patients. The results of this study can help ophthalmologists to be vigilant when they see these findings in a suspected case of COVID-19. In addition, wearing face masks and protective goggles or eye shields are recommended, especially in high risk contacts.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2): a Systemic Infection

To date, seven identified coronaviruses (CoVs) have been found to infect humans; of these, three highly pathogenic variants have emerged in the 21st century. The newest member of this group, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first detected at the end of 2019 in Hubei province, China. Since then, this novel coronavirus has spread worldwide, causing a pandemic; the respiratory disease caused by the virus is called coronavirus disease 2019 (COVID-19). The clinical presentation ranges from asymptomatic to mild respiratory tract infections and influenza-like illness to severe disease with accompanying lung injury, multiorgan failure, and death. Although the lungs are believed to be the site at which SARS-CoV-2 replicates, infected patients often report other symptoms, suggesting the involvement of the gastrointestinal tract, heart, cardiovascular system, kidneys, and other organs; therefore, the following question arises: is COVID-19 a respiratory or systemic disease? This review aims to summarize existing data on the replication of SARS-CoV-2 in different tissues in both patients and ex vivo models.

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.

COVID-19 and the eye: a review

BACKGROUND

To provide a review for general practitioners and medical specialists about the most common eye complaints and ocular manifestations in a COVID-19 patient.

METHODS

Reviewed 50 articles referenced in 4 databases from 20 December 2019 to 16 September 2020.

RESULTS

Of the 50 articles reviewed, 26 met the criteria for analysis and were included in the study. Among them were 5 reviews, 6 case series, 7 case reports, 4 cross-sectional studies, 2 systematic reviews, 1 cohort study and 1 correspondence. We found that the prevalence of ocular manifestations in patients during the course of COVID-19 varied between 0.8% and 31.6%, depending on the study design. Symptoms of acute conjunctivitis were the most frequent clinical findings. Acute phase reactants were also correlated to ocular manifestations and the severity of the systemic disease in many reports.

CONCLUSIONS

Ocular manifestations are not uncommon in COVID-19 patients and have been associated with higher levels of acute phase reactants as well as a higher degree of severity of the systemic disease. We recommend that all physicians consider COVID-19 as a differential diagnosis in the presence of acute conjunctivitis with or without systemic symptoms.

Possible Retinal Impairment Secondary to Ritonavir Use in SARS-CoV-2 Patients: A Narrative Systematic Review

Some reports described a possible ritonavir-related retinal toxicity. The objective of this research was to review and analyze previous studies conducted on ritonavir administration and retinal impairment in a narrative synthesis. PubMed was used to perform a systematic review of ritonavir effects and retinal damage. All studies up to December 2019 were considered. Seven single cases and one case series, reporting a total of 10 patients affected by retinal changes secondary to long-term ritonavir treatment, were included in the review. Variable degrees of outer retina and retinal pigment epithelium changes were detected in most of the patients, with two patients showing macular telangiectasia, four patients presenting intraretinal crystal deposits, two patients disclosing a bull's eye maculopathy, and two patients revealing midperipheral bone spicule-like pigment changes. In the present study, we hypothesized that the use of ritonavir in life-saving treatments of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) pneumonia might expose these patients to the risk of developing a retinotoxicity. We aimed to alert ophthalmologists on the importance of recognizing ritonavir-induced retinal impairment in SARS-CoV-2 patients. These findings are the target for personalized medicine.

Preserving Vision in the COVID-19 Pandemic: Focus on Health Equity

The coronavirus 19 (COVID-19) pandemic has overwhelmed our healthcare systems and caused the deaths of tens of thousands of Americans. Black and Hispanic individuals comprise a disproportionate number of those deaths, primarily because of pre-existing health conditions such as hypertension, obesity, and asthma. Health inequities that underlie these disparities also exist within ophthalmology around the world, and more ophthalmologists should advocate for healthcare reform that advances health equity. Immediate actions to reduce health disparities in ophthalmology during the pandemic include taking time to ensure all ophthalmology leadership and industry is diversified with people reflecting the fabric of their countries, embracing telemedicine to increase access to medical care, and advocating for legislation that will increase health insurance coverage during this unprecedented time. Longitudinal actions include recognizing structural racism as a root cause of health inequity and actively rejecting it through addressing modifiable risk factors, increasing cultural competency training, promoting diversity in the workforce, and global leadership.