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Introduction: Autoimmune and inflammatory thyroid diseases have been reported following SARS-CoV-2 infection or vaccination, but thyroid eye disease (TED) post-COVID-19 infection is less common. We describe a case of TED following SAR-CoV-2 infection in a patient with a history of Graves' disease. Case Description: A 59-year-old female with history of Graves' disease status post radioiodine ablation therapy in 2002. She developed post-ablative hypothyroidism which has been stable on levothyroxine 88 mcg daily. In January 2021, the patient's husband and daughter were diagnosed with COVID-19 infection. A few days later, the patient developed an upper respiratory tract infection associated with loss of sense of smell and taste consistent with COVID-19 infection. Three days later, she developed bilateral watery eyes which progressed to eye redness, eyelid fullness, retraction, and pain with eye movement over 1-month duration. Her eye examination was significant for severe periocular soft tissue swelling, lagophthalmos and bilateral exophthalmos. The laboratory workup was consistent with normal TSH 0.388 mIU/L (0.358-3.740 mIU/L) and positive TSI 1.01 (0.0-0.55). The patient was referred to an Ophthalmologist for evaluation of TED. He noted bilateral exophthalmos, no restrictive ocular dysmotility or compressive optic neuropathy (clinical activity score 4/7 points). CT scan of orbit showed findings compatible with thyroid orbitopathy. Based on clinical activity score of 4, treatment with Teprotumumab was recommended pending insurance approval. Discussion(s): Many cases of new-onset Graves' hyperthyroidism have been reported after COVID-19, with only a few associated with TED. Our patient has been in remission for 20 years before she developed COVID-19 infection with occurence of TED.This suggests that COVID-19 infection may have played a role. SARS-CoV-2 may act through several mechanisms, including breakdown of central and peripheral tolerance, molecular mimicry between viral and self-antigens, stimulation of inflammasome with release of type I interferon. In our patient, treatment with Teprotumumab was indicated due to Graves' orbitopathy clinical activity score greater than or equal to 3. In conclusion, it is very uncommon for TED to present after COVID-19 infection. Our case reinforces the speculative hypothesis that SARS-CoV-2 virus could have triggered an autoimmune response against eye antigens. There is a need for increased awareness about the link between COVID-19 and autoimmunity to help better define the management of patients.Copyright © 2023
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Since the introduction of COVID-19 vaccine, various adverse events have been reported including injection site pain, fatigue, headaches, and myocarditis. Cranial neuropathies and optic neuritis, have been also rarely reported, however, the significance of these autoimmune manifestations after the administration of COVID-19 vaccine remain controversial. In this report we present a case of myocarditis and bilateral optic neuritis that occurred in a young healthy male patient after the administration of first dose of mRNA-1273 vaccine (Moderna).Copyright © 2022 The Author(s)
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Background: There are various studies on coronavirus disease-2019 (COVID-19) from globally which are mainly focused on respiratory and other medical manifestations of the disease. There are few studies on ocular manifestations in COVID-19 and post-COVID-19 patients. Objective(s): We aim to investigate the ocular manifestations of hospitalized post-COVID-19 patients at a tertiary care institute in the North Eastern part of India. Material(s) and Method(s): This cross-sectional study was conducted among hospitalized post-COVID-19 patients 18 years and above during July 1, 2021-December 31, 2021. A universal sampling method was employed. A structured pro forma was used for data collection along with detailed ocular examination. Descriptive statistics were generated from collected data. Approval of the study was obtained from the institutional ethics committee. Result(s): A total of 105 patients were included in the study with ages ranging from 18 to 85 years and males constituting 63.8%. Around two-thirds of the patients (70, 66.7%) had not received any vaccination. Chest X-ray showed bilateral moderate consolidation in 59 (56.2%) patients. Twelve (11.4%) patients developed ocular signs and symptoms. Dry eye, redness of the eye, dimness of vision, itching, blurring of vision, and discharge from the eyes are some of the symptoms encountered. Two patients developed subconjunctival hemorrhage, one patient had a retinal hemorrhage and exposure keratopathy was detected in one patient. Conclusion(s): In this study, 11.4% of hospitalized post-COVID-19 patients have ocular manifestations. Post-COVID-19 syndrome could affect the eyes thus necessitating meticulous follow-up of patients who recovered from COVID-19.Copyright © 2023 Journal of Medical Society Published by Wolters Kluwer-Medknow.
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Introduction: Coronavirus Disease-2019 (COVID-19) can affect multiple system of body including eye. In eye, it can cause mild conjunctivitis, posterior segment involvement, neurosensory involvement and lethal opportunistic infection like mucormycosis. Associated co-morbidities, severity of COVID-19 infection and corticosteroids used in its management can affect ophthalmic involvement. Aim(s): To determine the frequency and various types of ophthalmic manifestation of patients with COVID-19. Material(s) and Method(s): This prospective observational study was conducted on indoor patients of Shree Krishna Hospital, a rural, tertiary care hospital affiliated with Pramukh Swami Medical College, Karansad, Gujarat, India, from 1st May 2021 to 1st January 2022. Second wave of COVID-19 was from 13th March 2021 to 19th June 2021. Patients' demographic data, details of COVID-19 infection severity score, oxygen requirement, use of corticosteroids, history of various co-morbidities and stages of Rhino-Orbital-Cerebral Mucormycosis (ROCM) (if present) were noted. Bedside ophthalmic examination was done with torch light, fluorescent strip, cobalt blue light of direct ophthalmoscope and fundus examination with indirect ophthalmoscopy under institutional COVID-19 guidelines. Descriptive Statistics {Mean, (SD), Frequency, (%)} were used for analysis of the collected data. Result(s): Out of 649 COVID-19 patients, 368 were male and 281 were female with mean age of 52.58 (+/-15.38) years. All over prevalence of ophthalmic manifestations was 9.86% (n=64 out of 649 patients). A total of 63 patients (9.71%) did not require any oxygen supplement, 352 patients (54.24%) required nasal prongs, 201 patients (30.97%) required non invasive ventilator support and 33 patients (5.08%) required mechanical ventilation. The 378 patients (58.24%) received cortico-steroids in oral or intravenous form. A total of 325 patients (50.1%) had diabetes,267 patients (41.1%) had hypertension, 29 patients (4.5%) had chronic kidney disease and 15 patients (2.3%) had thyroid disease. A total of 52 patients (8.01%) had conjunctivitis. Mean age of patients with conjunctivitis was 50.04 (+/-15.28) with male preponderance (n=30, 57.7%). Most common systemic presentation was fever (n=29,55.8%). Patients with conjunctivitis had high D-dimer (>500 ng/mL) (n=42;80.8%) and C-Reactive Protein (CRP) values (>3 mg/L) (n=39;75%). A total of 144 patients (22.2%) were vaccinated with COVID-19 vaccine first dose while ten patients (19.23%) out of 52 patients having conjunctivitis were vaccinated. Out of 649 patients, prevalence of ROCM was 1.85% (n=12) with mean age 58.58 years (+/-9.71 years) and male preponderance (n=8, 66.66%). Nine out of twelve patients had high blood sugar levels (mean level 340 mg/ dL) at the time of admission. Out of twelve, eight patients had received corticosteroids for management of COVID-19 infection. Six patients of ROCM (50%) did not require any oxygen support while two patient (16.7%) required nasal prongs for mean 7.50 days and four patient (33.3%) required non invasive ventilator support for mean 7.33 days (+/-2.5 days). One patient had stage 2C disease, one had stage 3B, five patients had stage 3C while five patients had stage 4C disease. Conclusion(s): Ocular manifestations of COVID-19 range from conjunctivitis to ROCM. Conjunctivitis has mild and self-limited course while ROCM is sight threatening and life-threatening condition, if not treated appropriately.Copyright © 2023 Journal of Clinical and Diagnostic Research. All rights reserved.
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Aim: The current study aimed to assess the effect of refractive errors among school children due to online classes. Material(s) and Method(s): School-going children who were attending online classes between five and fifteen years were subjected to ophthalmic evaluation. A questionnaire including sections like demographics, gadget use, on-screen time, and physical complaints was administered to collect the required data. Result(s): The participants in our study had a mean age of 9 +/- 2 years (range 5-15 years) of whom 48.4% (n = 140) were males and 51.6% (n = 149) were females. There was a predominance of myopia (86.5%) in children where 44.6% of them have newly developed refractive errors. Around 70 (67.8%) children with a previous refractive error have been shown to have progression of refractive error. Conclusion(s): Our study reports that children were exposed to prolonged screen time which led to a rise in the number of myopia cases.Copyright © 2022 Wolters Kluwer Medknow Publications. All rights reserved.
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Melanoma of unknown primary (MUP) was originally defined in 1963 as melanoma in the subcutaneous tissue, lymph nodes or visceral organs without the presence of a cutaneous, ocular or mucosal primary. The incidence of MUP is reported to be between 1% and 8% of all melanomas. MUP can be divided into lymph node involvement only and organ metastases. The aetiology of MUP is elusive. Possibilities proffered include an unrecognized melanoma, a previously excised melanoma that was misdiagnosed as benign, a primary melanoma that has completely regressed or the de novo malignant transformation of an aberrant melanocyte within a lymph node. We report our experience in a single tertiary referral centre. A database of all melanomas diagnosed between January 2018 and December 2021 was analysed for MUP. The total number of melanomas diagnosed in that timeframe was 298. Six patients (three males, three females) were identified as having MUP, with an incidence of 2%. Median age was 63.3 years (range 45-84). One (17%) presented with primary dermal metastatic deposits, 67% (n = 4) presented with isolated lymph node metastases, 0% presented with visceral metastases and 17% (n = 1) presented with isolated brain metastases. All six patients were reviewed by dermatology and ophthalmology. Fifty per cent (n = 3) were reviewed by ENT. One (17%) was referred to gynaecology. No primary melanoma was identified in any of the patients. All patients underwent a positron emission tomography-computed tomography (CT) scan to investigate for further metastases, and all underwent dedicated brain imaging via CT and magnetic resonance imaging. All patients underwent surgical resection of their MUP, and all were reviewed by medical oncology, with 83% (n = 5) undergoing treatment with immunotherapy. There have been no associated deaths to date. In five patients (83%) the MUP was diagnosed in 2021, and one (17%) was diagnosed in 2018. Recent studies have shown the impact of the COVID- 19 pandemic on the presentation of cutaneous melanoma, including an increased Breslow thickness at the time of presentation vs. a similar period pre-COVID-19. Our data indicate an increased rate of MUP presenting after the onset of the COVID-19 pandemic;however, given the low number overall, no conclusions can be drawn. There is no current literature regarding the increased rate of MUP since the COVID-19 pandemic. Further studies are required to investigate this. Recommendations for the evaluation of those with MUP include a full skin examination by a dermatologist and ocular examination to exclude primary melanoma. Patients should undergo imaging of the brain, thorax, abdomen and pelvis to assess disease burden. Referral to otorhinolaryngology can be considered to assess for mucosal melanoma of the nasopharynx. Gynaecology referral should be considered for those with inguinal lymphadenopathy. MUP is rare. Guidelines for the investigation of MUP are currently lacking and are needed to ensure the delivery of consistent evidence-based care for patients.
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Backgrounds: To report the first case of left optic neuritis and perineuritis associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) BNT162b2 mRNA vaccination. Case presentation: A 39-year-old woman was referred and admitted to our hospital due to transient left visual field abnormality with left ophthalmalgia and headache 12 days after the first vaccination dose of SARS-CoV-2 (BNT162b2). On admission (Day 2), she presented with left ophthalmalgia and headache without any other neurological deficits including the movement of eyeballs, visual field, visual acuity, or nystagmus. MRI on Day 2 suggested slight left optic neural swelling;Gadolinium-enhanced MRI on Day 4 revealed left optic perineuritis. Test for serum anti-aquaporin 4 antibody was negative, whereas anti-myelin oligodendrocyte glycoprotein (MOG) antibody was positive. She was diagnosed with left optic perineuritis after SARS-CoV-2 mRNA vaccination. Her visual disturbance never recurred and her ophthalmalgia and headache subsided only with anti-inflammatory agents. Discussion(s): Many cases of optic neuritis associated with vaccinations have been reported except for SARS-CoV-2 BNT162b2 mRNA. To our knowledge, only one neuromyelitis optica case was associated with anti-MOG antibody. Therefore, we propose that SARS-CoV-2 mRNA vaccination may induce transient optic neuritis and perineuritis, associated with anti-MOG antibody in the present case. Conclusion(s): This is the first case of left optic neuritis and perineuritis associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) BNT162b2 mRNA vaccination.Copyright © 2022
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Introduction The objective of this study was to identify barriers that affect adherence to the management of diabetic retinopathy (DR) in an urban ophthalmology clinic. Patient beliefs regarding diabetic eye care, transportation to the eye clinic, the COVID-19 pandemic, and treatment with panretinal photocoagulation (PRP) or anti-vascular endothelial growth factor (anti-VEGF) injections were investigated. Materials and methods The original Compliance with Annual Diabetic Eye Exams Survey (CADEES) included 44 statements designed with a 5-point Likert scale to assess patients' beliefs and understanding of their eye health and the importance of diabetic eye examinations. This survey was modified to include additional statements regarding the COVID-19 pandemic and free-response questions about transportation barriers and patients' subjective experiences with PRP or anti-VEGF injections. A total of 365 patients with a diagnosis of any stage of DR from SLUCare Ophthalmology were identified as potential participants to complete the telephone survey. Patients were classified as non-adherent if they did not have a dilated eye examination within the past year, missed a scheduled follow-up appointment for DR care within the past year, or missed an appointment for anti-VEGF injections or PRP. The mean Likert scores for each CADEES statement were compared between the adherent and non-adherent groups using independent samples t-tests. Demographics and clinical indicators were also reported and compared between the two groups. Results Out of 365 patients, 68 completed the modified CADEES. Twenty-nine patients were adherent, and 39 patients were non-adherent. Results from six of the 54 CADEES statements were significantly different between the adherent and non-adherent groups. These statements addressed patients' perception of their eye health, self-confidence in making an eye appointment, knowing someone with diabetic eye complications, self-confidence in controlling blood sugar, ability to use public transportation during the COVID-19 pandemic, and prioritizing eye health during the pandemic. There were no significant differences in clinical indicators or demographics between the adherent and non-adherent groups. Of the participants, 39.7% offered reasons for why transportation to the eye clinic was difficult. Patients suggested three novel reasons for missing eye appointments that were not specifically addressed in the CADEES. Fourteen unique barriers were reported for non-adherence with PRP or anti-VEGF injections. Conclusions The CADEES is a thorough tool for evaluating social barriers impacting adherence with DR appointments in an urban ophthalmology clinic. The survey did not identify any clinical or demographic risk factors for non-adherence in this patient population. Decreased patient self-efficacy may lead to non-adherence with the management of DR. The COVID-19 pandemic impacted the adherence of a small percentage of patients.
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Objectives: For a definitive diagnosis of COVID-19, respiratory tract samples are evaluated by polymerase chain reaction (PCR). In our study, PCR using a tear sample was used to diagnose COVID-19, and it was questioned whether it was a screening method. Unlike the general practice, Schirmer strips were used instead of a swab for tear sample collection in this study. In addition, the diagnostic values of serum procalcitonin (PCT), C-reactive protein (CRP), and Neutrophil (NEU) count in predicting COVID-19 disease from tears were also questioned. Method(s): A total of 94 patients who were positive for COVID-19 by PCR test were included in this study. Tear samples were obtained from patients with Schirmer strips, commonly used in eye examination, and studied with the PCR technique. CRP, PCT value, and NEU count were also compared between the positive and negative groups of the PCR. The obtained data were analyzed using the R Studio software, and the results were considered statistically significant for p<0.05. Result(s): Of these patients, 61 (64.9%) tear PCR was negative, and 33 (35.1%) tear PCR was positive. The mean age was 61.72 +/- 17.62 years. The patients were divided into two groups: tear PCR positive and negative. There was no significant age difference between these groups. As a result of ROC Analysis;When serum PCT, CRP, and NEU % values were examined in predicting COVID-19 disease from tears, it was seen that CRP (p=0.027) and especially PCT (p=0.003) values of patients with PCR-positive were significantly higher. Conclusion(s): PCR study on tears collected with Schirmer strips is a different and non-invasive method, but it was concluded that the proposed method could not be used as a screening test. In addition, significantly higher serum PCT values were found in patients with COVID-19 positivity in tears (p<0.05). Copyright © 2022 the author(s), published by De Gruyter.
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BACKGROUND AND AIM: In the pregnancies of severe SARS-CoV-2, which resulted in maternal death, the fetus is more vulnarable in terms of being affected by systemic complications. The aim of this study is to evaluate the ocular findings of newborns whose mothers passed away due to SARS-CoV-2, by considering possible different modes of involvement. METHOD(S): Single-center retrospective observational study. A total of 9 newborns were evaluated ophthalmologically. Demographic data, polymerase chain reaction(PCR) test results and ophthalmological findings were collected. RESULT(S): Gestational age at ranged from 27 to 37 weeks (mean 31,55 +/- 3,16 weeks), and the birth weights varied from 990 g to 2160 g (mean 1481+/-397g). Mean ICU stay was 28.7 days. Positive PCR was positive for SARS-CoV-2 in 2 newborns.Ocular examination was performed within the first 30 days. Neonatal conjunctivitis (n=2), corneal edema (n=1), retinopathy of prematurity (ROP) (n=6) (treatment requiring ROP n=3) and intraretinal bleeding(n=2)was observed.One of the babies with a positive result had ROP that did not require treatment, and the other had conjunctivitis with intraretinal hemorrhage. CONCLUSION(S): Despite numerous studies, the impact of SARS-CoV-2 on the fetus remains unclear in many ways. Case reports indicate that maternal-fetal vertical transmission is not common.Exposure to intrauterine inflammation and placental changes may cause multisystemic problems in the neonatal period in exposed infants.The need for intensive care in the mother increases the possibility of fetal vascular malperfusion, premature birth rate and related problems.The detected ocular pathologies are not specific to SARS-CoV-2 infection.Additional controlled studies are required to correlate the findings with the disease. (Figure Presented).
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Purpose: To highlight the considerations in clinical diagnosis and management of ophthalmic vein thrombosis through a challenging case of asymptomatic posttraumatic bilateral superior ophthalmic and cavernous sinus thrombosis. Method(s): A review of electronic medical records. Result(s): A 54-year-old female with no significant past medical history presented to a tertiary trauma and referral hospital two hours after falling from a ladder and sustaining significant head and torso polytrauma. She had a second dose of BNT162b2 COVID-19 mRNA vaccination two weeks earlier. Contrast computed tomography imaging confirmed the presence of bilateral superior and inferior ophthalmic vein thrombi, and suspected cavernous sinus thrombi without carotid-cavernous fistula. The patient's presentation occurred in the absence of any neurological or ophthalmic signs or symptoms, and her visual acuity remained normal throughout follow-up. A serological inflammatory, infectious, and thrombotic screen was negative. Repeat computed tomography imaging demonstrated successful resolution of all thrombi following treatment with systemic anticoagulation. Conclusion(s): This unusual case of bilateral ophthalmic vein thrombi highlights a challenging diagnosis that should not be overlooked despite a normal neurological and ophthalmic examination. Although the cause of SOVT was likely post-traumatic, contribution from recent nVoC-19 vaccination was investigated.
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Purpose : Preliminary evidences from the literature, together with our everyday clinical practice and patients reporting, led us to hypothesize that dry eye (DED) symptoms related to some COVID-19 mitigation measures might be a common problem and a relevant issue. We designed this study in order to assess and to monitor DED symptoms' changes from 2019 to 2021, in both DED patients and healthy subjects, and to investigate their relationship with homeworking and facemask wearing. Methods : We retrospectively reviewed the medical records of patients who, between November and December 2019 (V19), had undergone an eye exam including quantification of Ocular Surface Disease Index (OSDI) score at the Eye Clinic San Giuseppe Hospital, Milan. Between November and December 2020, we performed a telephone survey (V20) contacting these patients. The survey was repeated between November and December 2021 (V21). The telephone survey included the OSDI 12-items and a custom-made questionnaire exploring type of job or occupation, home working, screen time, type and average time of face mask-wearing, and recent onset and worsening of DED-related symptoms. We investigated the difference among V21, V20 and V19 DED symptoms, the rate of subjects with OSDI increase > OSDI minimal clinically important difference (MCID), and associations between DED symptoms, face masks wearing, VDT usage and home working. Results : Of 120 subjects with V19 OSDI≤12, 43 (36%) and 39 (32%) showed OSDI>12 at V20 and at V21, respectively. OSDI was significantly correlated with duration of face masks use (V20 r= 0.29;P<0.01. V21 r= 0.23;P<0.01) and heavy mask users had a significantly higher OSDI (P<0.05). V20 and V21 OSDI was significantly higher in home-workers (P<0.05) but we did not find a significant correlation between V21 OSDI and referred number of VDT use (r= 0.07;P=0.41). Of 70 patients with V19 OSDI>12, 18 (26%) and 24 (34%) showed symptoms worsening >MCID at V20 and V21, respectively. The percentage of OSDI worsening >MCID was significantly higher among heavy face masks users (73% vs 12%;P<0.01, Fisher test). The percentage of OSDI worsening >MCID was significantly higher in home workers at V20 but not at V21. Conclusions : Some COVID-19 mitigation strategies seem to have a significant role in triggering DED symptoms onset or worsening. This issue persisted during the second pandemic year, with weaker correlation to presumed trigger factors.
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Purpose : Coronavirus-19 (COVID-19) has been associated with ophthalmic manifestations. The relationship between tear film SARS-CoV-2 RNA, timing of illness and eye disease are unknown. We evaluated hospitalized COVID-19 inpatients for retinopathy and tear film viral RNA. Methods : Hospitalized COVID-19 inpatients were offered enrollment from January-June 2021. Full dilated ophthalmic examination and conjunctival swabs were taken for triplex RT-PCR for SARS-CoV-2 RNA targeting N2, E and RNAse P. Demographic, clinical outcomes and laboratory data were collected. Univariate and multivariate analyses of systemic disease and laboratory risk factors for retinopathy and SARS-CoV-2 RNA detection were assessed. Results : Sixty patients were prospectively enrolled in this cross-sectional, observational study. The mean age was 58.8 years (Standard deviation [SD] 15.2 years) and 29 (48%) were female. Retinopathy associated with COVID-19 in 12 of 60 patients (20%). Univariate analyses revealed that younger age, greater body mass index (BMI) and extracorporeal membrane (ECMO) requirement were associated with increased odds of COVID-19 retinopathy. The mean age (SD) of patients with COVID-19 retinopathy was 49.0. (11.6) compared to 61.2 (15.1) years in individuals without retinopathy (p=0.01). The mean BMI was 38.8 (9.8) in patients with retinopathy compared to 31.8 (9.0) in those without retinal disease findings (p=0.04). ECMO requirement was observed in 33% of patients with retinopathy compared to 8% in those without retinopathy (p=0.04). Multivariate analyses trended towards increased risk of retinopathy with younger age (aOR 0.95 (95% CI 0.90- 1.01, p=0.095) and with increased BMI (aOR. 1.08, 95% CI 1.00-1.18, p=0.056). Fifteen of 60 patients (25%) tested positive in their tear film for SARS-CoV-2 RNA with a trend towards a shorter length of illness and hospitalization in patients who were positive. The N2 gene was particularly sensitive with 18 of 19 eyes (94.7%) showing N2-positivity (with or without E gene detection), including 2 patients in whom the B.117 / B.1.525 alpha or ?United Kingdom? variant was detected. Conclusions : A 20% rate of retinopathy was observed and SARS-CoV-2 RNA within tear film was detected in 25% of hospitalized COVID-19 patients. Continued infection control precautions are required given the risk of viral RNA in tear film, which may also be sensitive for the detection of COVID-19 variants.
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Purpose : While severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is well known for its respiratory complications, ocular manifestations are emerging. This case report describes a patient with bilateral optic neuritis associated with coronavirus disease 2019 (COVID-19). Methods : A 46-year-old male presented with two weeks of pain with eye movement immediately after testing positive for COVID-19 and four days of bilateral blurry vision. Data including history, ocular examination, Humphrey visual field testing (HVF), magnetic resonance imaging (MRI), and serological testing was collected. Results : Visual acuity (VA) was 20/100 in the right eye (OD) and 20/70 in the left eye (OS) with pinhole VA of 20/40 in each eye. Pupil exam, intraocular pressures, and confrontational visual fields were normal. Ocular motility was full, however the patient endorsed pain with eye movement in all directions. The right optic nerve had blurred disc margins while the left optic nerve was unremarkable on exam. Color vision was decreased to 13/15 by Ishihara testing in each eye. MRI of the brain and orbits revealed bilateral thickening and T2 hyperintensity and hyperenhancement of the intercanalicular and intraorbital optic nerves with sparing of the nerve sheath and no demyelinating lesions (Figure 1). Bilateral central scotomas were seen on HVF (Figure 2). At this point, the patient's clinical picture was concerning for optic neuritis associated with COVID-19. A complete blood count, comprehensive metabolic panel, myelin-oligodendrocyte glycoprotein antibody, and aquaporin 4 antibody were unremarkable. Testing for tuberculosis, sarcoidosis, syphilis, thyroid disease, and rheumatologic and autoimmune disorders was normal. The patient was treated with corticosteroids. Within three to six weeks, the patient's symptoms and abnormal exam findings resolved. Conclusions : Infectious pathogens and their subsequent inflammation can cause optic neuritis. It is postulated that T cells release inflammatory mediators and cytokines that cross the blood brain barrier and lead to destruction of myelin, neuronal cell death, axonal degeneration, and vision loss. SARS-CoV-2 could cause a similar inflammatory response leading to optic neuritis and is important to consider in cases without a clear etiology.
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Purpose : To explore whether the COVID-19 lockdown increased the incidence of myopia among age-school children. Methods : Retrospective study recruiting children aged 5-12. Selection: random. Inclusion criteria: healthy children presenting for an eye exam since 2016. Exclusion criteria: presence of ocular comorbidities other than refractive error, spherical equivalent (SE) less than -4D or greater than +4D, BCVA less than 20/20, blepharoptosis, media opacities, corneal or retinal dystrophies, strabismus, amblyopia, nystagmus, or concurrent therapy with atropine 0.01%. Outcome measure: age measured in months, SE of the right eye (RE) measured in diopters (D) under cycloplegia (cyclopentolate 1%). Statistical analysis: ANOVA, Chi-square, Tukey's test. Significance: p < .05. Results : A total of 803 children. In the years prior to COVID-19, the mean SE ± SD diopters in the RE: 0.54 ± 1.49 D in 2016 (n = 160), 0.43 ± 1.84 D in 2017 (n = 145), 0.34 ± 1.41 D in 2018 (n = 152), 0.35 ± 1.75 D in 2019 (n = 166) (ANOVA, p = .659) (Fig. 1). In 2021 (n = 180), the mean SE was -0.08 ± 1.44 D (ANOVA, p = .005). Using the Tukey's test, the mean SE of 2021 changed by -0.619 D 95% CI [-1.091, -0.147] and -0.501 D 95% CI [-0.986, -0.016] as compared to the SE of 2016 and 2017, respectively (Fig. 2). Mean age was comparable in all groups (ANOVA, p = .307). The decrease of the mean SE of the 2021 group corresponds to an increase in the percentage of myopes (≤-0.5D) and a decrease in the percentage of hyperopes (≥ 2D). Myopes represent the 24.10% of children aged 60-96 months, and 63.86% of children aged 97-144 months. Hyperopes represent 9.64% of children aged 60-96 months, and 6.02% of children aged 97-144 months. This represents a statistically-significant increase in the number of myopes (Chi-square, p = .016) and decrease in the number of hyperopes (Chi-square, p = .001), as compared to the previous years (2016- 2019). Conclusions : This retrospective study shows a statistically-significant decrease in the mean SE in children aged 5-12 in the year following the COVID-19 lockdown (2021). The percentage of myopes has increased significantly, while the percentage of hyperopes has decreased. Children aged 8-12 years showed the greatest refractive change. The lifestyle changes imposed by the lockdown were likely responsible for the increased prevalence of myopia observed in 2021.
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Purpose : 85% of US adults have a smartphone with 87 million people using a health or wellness app monthly in 20201. There are 350,000 eHealth apps2. Roughly 33M adults in the US have the chief complaint of vision loss. An estimated 93M are at high risk for serious visual impairment3 . Only half have visited an eye doctor in the past 12 months, due to COVID 193. American adults over the age of 18 fall into the demographic of mobile app users. Do free apps help our eye patients during this pandemic? Methods : We used the search terms “vision test” and “eye exam” in the Apple App Store to compile a list of the top 10 free apps. We looked for how many free apps have eye charts that are “recognized” such as Snellen chart, Landolt C, LogMAR chart, Amsler grid & Visual Field. Control: Inclusion criteria: 1) free;2) English language;3) ≥50 reviews, ≥4 star rating in the Apple App store. Exclusion criteria: 1) foreign languages 2) paid apps. Results : Results: Top 10 iOS apps (from most downloads to least) in the Apple App Store seen in Table 1. For all iOS apps, Snellen vision test: 9/10;Landolt C: 1/10;LogMAR chart: 3/10;Amsler grid: 3/10;Visual field 1/10. Only 1 app connected you with a local optometrist or ophthalmologist. Only 3/10 apps had >1K reviews. iOS apps do not provide a number of downloads. Conclusions : Although many adults have not received an eye exam over the past 12 months, physicians can still connect with their patients through public education with the use of mobile apps. However, current eHealth apps can improve their content for eye patients.
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Purpose : Acute posterior multifocal placoid pigment epitheliopathy (APMPPE) is a generally self-limited disease with a good prognosis and resolution of symptoms between 4 weeks and 6 months. Retinal imaging is used to establish the diagnosis;however, the resolution of routine diagnostic imaging to assess changes at the photoreceptor level is limited. Here we explored outer cellular retinal structure of APMPPE lesions in a patient 4 years after initial presentation and 8 months after recurrent scotoma symptoms in the same region as her initial APMPPE scotomas a few days after her first COVID-19 vaccine. Methods : The subject underwent a complete eye exam and high resolution imaging. Outer retinal structure was assessed using spectral domain optical coherence tomography (SD-OCT), and the photoreceptor mosaic was imaged using both confocal and split detection adaptive optics scanning light ophthalmoscopy (AOSLO). Results : SD-OCT identified a subtly irregular ellipsoid zone (EZ) band in the area of a previous APMPPE lesion, improved from initial presentation and initial visit after reactivation. Confocal AOSLO (Figure A) revealed an abrupt transition from dense regularly spaced cones to a disrupted photoreceptor mosaic. However, confocal AOSLO signal can be difficult to interpret in the presence of debris or non-waveguiding cones. Split detection AOSLO (Figure B) highlights cone inner segments providing a clearer view of cone distribution even in the absence of waveguiding and revealed reduced photoreceptor density in disrupted areas (Figure A and B '∗'). Conclusions : COVID-19 vaccination may induce reactivation of APMPPE symptoms. Despite improved EZ band structure by SD-OCT in the areas of previous APMPPE lesions, AOSLO revealed several focal areas of persistent subclinical photoreceptor loss. Split detection AOSLO allows for more precise assessment of photoreceptor structure and highlights the variability in inner segment changes throughout retina lesions. This demonstrates the potential utility of split-detector AOSLO for assessment of photoreceptor structure alterations in retinal uveitic diseases such as APMPPE. (Figure Presented).
ABSTRACT
Purpose : Limited access to eye-care among Latinos can lead to missed Vision Threatening Diseases (VTDs) defined as Age-related Macular Degeneration (AMD), cataracts, Diabetic Retinopathy (DR) and glaucoma. As 50% of the people with VTD's are unaware of their condition made worse during COVID-19, comprehensive eye screenings to assess ocular wellness was implemented using telemedicine, Artificial Intelligence (AI) and robotic consultations. Methods : State-sponsored screenings were conducted at a church in West New York, NJ (78% Latino, mostly from Colombia) over 3 weekends during the 2021 Pandemic. All participants had received two-dose vaccinations and wore a surgical mask during screenings. Nine first-year medical students and 6 community volunteers took part in the wellness evaluation including: medical history, blood pressure, visual acuity, automated refraction, puff tonometry, 45-degree non-mydriatic retinal photography AI. To confirm findings: 6-micron resolution ocular coherence tomography (OCT) B-scan was performed. Screened subjects had their data reviewed by an onsite ophthalmic grader using a Spanish-speaking interpreter. As 80% of screened subjects are lost to follow-up, remote robotic ophthalmology consultation via HIPAA compliant Wi-Fi was utilized in real-time to connect with an off-site ophthalmologist. Results : 153 subjects, (71 Female (46%), median age 55) had 127 ocular findings (Table 1) found in 85 (55%) subjects, of which 98% of findings were previously unknown and 40 (47%) classified as VTD. 23(15%) subjects had multiple findings. OCT confirmed 23 cases of AMD and glaucoma. AI referred 39 cases. 36 individuals took part in robotic virtual consults. Findings were: cataracts 70 (45%), glaucoma 32 (20%), and AMD 25(16%). Among those with findings, 82% were uninsured and 90% had >2 years since last eye exam. 32 (32/153) subjects had undertreated or untreated hypertension. 93% were un-familiar with telemedicine. Conclusions : Latinos without health insurance and ease of access to eyecare may have a higher burden of multi-VTDs. An exception was DR which could be a limitation of population bias. This pilot study supports comprehensive wellness eye screenings that may allow for early detection, confirmation, and referral of single or multiple VTD in high-risk low-income communities. Further studies are needed using larger sample populations. (Figure Presented).
ABSTRACT
CASE: A 48-year-old female with no medical history presented with 2 days of decreased vision in the right eye. She reported painless blurry vision that progressed to near complete vision loss. The vision loss was accompanied by one month of progressively worsening cough, body aches, and subjective fevers. She denied smoking and reported no sick contacts. Physical exam was notable for submandibular lymphadenopathy, bilateral conjunctival injection, and grossly decreased vision of the right eye. She also endorsed decreased sensation in bilateral lower extremities distally. Her initial labs showed leukocytosis (13), thrombocytosis (754), and elevated inflammatory markers (ESR 105 and CPR 359). A chest CT showed bilateral upper lobe consolidations and scattered mass like opacities bilaterally. Ophthalmic exam of the right eye revealed multiple small retinal infarctions consistent with paracentral acute middle maculopathy. A CT head was negative and TTE showed no vegetation. Additional testing revealed negative TB, COVID, and normal complements. Initial ANCA testing was negative, however a repeat test was strongly positive for ANCA with PR3 significantly elevated to 428. She was diagnosed with granulomatosis with polyangiitis (GPA) vasculitis and treated with prednisone and started induction therapy of Rituximab. IMPACT/DISCUSSION: GPA is a small-medium vessel necrotizing vasculitis and the most common anti-neutrophil- cytoplasmic-antibody (ANCA) associated vasculitis. GPA classically involves the upper respiratory tract, lungs, and kidneys referenced by the ELK criteria (ENT, Lung, Kidney) commonly used for diagnosis. ENT findings are present in 70-100% of cases with the nasal cavity and paranasal sinuses most commonly involved. Roughly 50% have pulmonary involvement on presentation, as in this patient, while only 10-20% have initial renal involvement. A prodrome of systemic symptoms including body aches and fevers is often present. GPA is closely associated with c-ANCA, with autoantibodies to proteinase 3 (PR3) positive in over 80% of cases. This patient did have prodromal symptoms yet her primary presenting symptom of vision loss was atypical. Eye involvement is not part of the diagnostic triad yet it can occur in GPA. When it does present, it usually manifests as scleritis, conjunctivitis, or uveitis. Retinal infarctions, as seen in this patient, are uncommon and make this case an atypical presentation of GPA. Additionally, ANCA positivity is related to disease activity and a negative ANCA should not exclude GPA from a differential. Not all patients will be ANCA positive on initial presentation and 10% of patients with GPA will remain ANCA negative. CONCLUSION: Providers should consider atypical presentations of GPA in addition to the classic triad of ENT, Lungs, and Kidneys. Renal manifestations are often missing initially and involvement of other systems, such as ocular, can take place. With a positive c-ANCA and high clinical suspicion, treatment should not be delayed.