Neuro-Ophthalmic Complications of COVID-19 Infection and Vaccination.

The COVID-19 pandemic has led to the identification of new disease phenotypes associated with infection by the SARS-CoV-2 virus. This includes multiple neuro-ophthalmological sequelae, which have been associated with COVID-19 infection and administration of COVID-19 vaccines. Some of these associations have a plausible pathophysiological link to the infection or vaccination but true causation has yet to be established. We review the literature for associations reported between COVID-19 infection or vaccination and neuro-ophthalmic sequelae and review the potential pathophysiological processes that may underlie these associations.

An eye to the future: Acute and long-term neuro-ophthalmological and neurological complications of COVID-19.

COVID-19 has had a significant impact on the global population and has produced compelling evidence of non-pulmonary organ dysfunction, including the nervous system. It is vital that specialists in ophthalmology and neurology are informed of the potential complications of COVID-19 and gain a deeper understanding of how COVID-19 can cause diseases of the nervous system. In this review we detail four possible mechanisms by which COVID-19 infection may result in neurological or neuro-ophthalmological complications: (1) Toxic and metabolic effects of severe pulmonary COVID-19 disease on the neural axis including hypoxia and the systemic hyper-inflammatory state, (2) endothelial dysfunction, (3) dysimmune responses directed again the neuroaxis, and (4) direct neuro-invasion and injury by the virus itself. We explore the pathological evidence for each of these and how they may link to neuro-ophthalmological disorders. Finally, we explore the evidence for long-term neurological and neuro-ophthalmological complications of COVID-19, with a focus on neurodegeneration.

Impact of COVID-19 on Neuro-Ophthalmology in the United States: A National Survey.

PURPOSE: To evaluate the impacts of the COVID-19 on neuro-ophthalmology practice in the United States. DESIGN: Cross-sectional study. METHODS: The North American Neuro-ophthalmology Society distributed a survey on the impact of COVID-19 on neuro-ophthalmic practice to its members. The survey consisted of 15 questions regarding the impact of the pandemic on neuro-ophthalmic practice and perspectives. RESULTS: Twenty-eight neuro-ophthalmologists practicing in the United States responded to our survey. In this survey, 64% of survey respondents were male (n = 18), while 36% were female (n = 10). The average age of a respondent was 55 years old. According to 77% of survey respondents, various neuro-ophthalmic diseases were reported to have worsened during the pandemic including idiopathic intracranial hypertension, compressive optic neuropathy, optic neuritis, and giant cell arteritis. CONCLUSIONS: This survey represents one of the largest studies to describe the impact of the COVID-19 pandemic of neuro-ophthalmology. Given the underrepresentation of neuro-ophthalmology in the United States as described in the literature, this study strengthens the need for more neuro-ophthalmologists to provide timely care, particularly during the pandemic. Further interventions to incentivize the pursuit of neuro-ophthalmology training may help combat the effects of COVID-19 on neuro-ophthalmic conditions.

Ocular manifestations of COVID-19 in the pediatric age group.

The coronavirus disease 2019 (COVID-19) is now known to be associated with several ocular manifestations. The literature thoroughly discussed those that affect adults, with a lesser focus in the pediatric age group. We aim to outline the various pediatric ocular manifestations described in the literature. The manifestations may be divided into isolated events attributed to COVID-19 or occurring in the new multisystem inflammatory syndrome in children (MIS-C), a novel entity associated by COVID-19 infection. Ocular manifestations have virtually affected all ages. They manifested in neonates, infants, children, and adolescents. Episcleritis, conjunctivitis, optic neuritis, cranial nerve palsies, retinal vein occlusion, retinal vasculitis, retinal changes, orbital myositis, orbital cellulitis were reported in the literature with this emerging viral illness. Conjunctivitis was the most common ocular manifestation in MIS-C in nearly half of the patients. Other ocular manifestations in MIS-C were anterior uveitis, corneal epitheliopathy, optic neuritis, idiopathic intracranial hypertension, and retinitis. The clinical outcome was favorable, and children regain their visual ability with minimal or no deficits in most of the cases. Further follow-up may be warranted to better understand the long-term effects and visual prognosis.

Can Tele-Neuro-Ophthalmology Be Useful Beyond the Pandemic?

PURPOSE OF THE REVIEW: Neuro-ophthalmologists rapidly adopted telehealth during the COVID-19 pandemic to minimize disruption to patient care. This article reviews recent research on tele-neuro-ophthalmology adoption, current limitations, and potential use beyond the pandemic. The review considers how digital transformation, including machine learning and augmented reality, may be applied to future iterations of tele-neuro-ophthalmology. RECENT FINDINGS: Telehealth utilization has been sustained among neuro-ophthalmologists throughout the pandemic. Adoption of tele-neuro-ophthalmology may provide solutions to subspecialty workforce shortage, patient access, physician wellness, and trainee educational needs within the field of neuro-ophthalmology. Digital transformation technologies have the potential to augment tele-neuro-ophthalmology care delivery by providing automated workflow solutions, home-based visual testing and therapies, and trainee education via simulators. Tele-neuro-ophthalmology use has and will continue beyond the COVID-19 pandemic. Digital transformation technologies, when applied to telehealth, will drive and revolutionize the next phase of tele-neuro-ophthalmology adoption and use in the years to come.

Ophthalmology in a virtual world: The impact of the COVID-19 pandemic on specialty conferences

Purpose : The COVID-19 pandemic led to unprecedented cancellation or alteration of healthcare events and medical conferences around the world. Many ophthalmology conferences transitioned to virtual interfaces, and the impact of this transition on the ophthalmology community is unclear. The authors wish to objectively define the impact of the COVID-19 pandemic on subspecialty ophthalmology conferences. Methods : This study included data from the following five ophthalmology conferences from 2019, 2020, and 2021, as available: American Glaucoma Society (AGS), American Society of Ophthalmic and Plastic Reconstructive Surgery (ASOPRS), American Society of Cataract and Refractive Surgery (ASCRS), North American Neuro-Ophthalmology Society (NANOS), and Women in Ophthalmology (WIO). Data requested from organizations included the following, as available: Number of total conference attendees, number of attendees stratified by level of training, number of attendees stratified by identified gender, and number of research s or presentations (submitted and/or accepted). This study has been approved by the City University of New York Institutional Review Board. Results : In our study, 60% of organizations demonstrated an increase in number of attendees when using a virtual interface compared to their in-person events. 80% of organizations demonstrated a marked increase in attendance by trainees on their virtual interfaces. 60% of organizations displayed a decrease in number of submitted s when using a virtual interface. 40% of organizations experienced an increase in number of accepted posters and presentations through a virtual platform. Conclusions : Virtual conference interfaces have the potential to increase overall attendance and research participation within the ophthalmology community. Organizations should consider a hybrid model that incorporates aspects of both virtual and in-person interfaces to potentially maximize attendance, outreach, dissemination of information, opportunity, and minimize costs.

Non-arteritic anterior ischemic optic neuropathy in COVID-19 infection - A case report.

Purpose: To report a case of a non-arteritic anterior ischemic optic neuropathy (NAION) in the setting of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Observations: A 60-year-old healthy female without any risk factors for vasculopathy, presented with an acute painless diminution of vision noticed in the lower half of the visual field in the left eye. She was diagnosed with NAION in the setting of a recent SARS-CoV-2 infection. Conclusions and importance: The purpose of this case report is to supplement our knowledge about the neuro-ophthalmological complications of COVID-19 in the form of NAION which might occur even in the early stages of the infection.

Atypical presentation of juvenile multiple sclerosis in a patient with COVID-19.

PURPOSE: To report our experience with a case of a very atypical clinical onset of multiple sclerosis in a young boy during a COVID-19 infection. CASE REPORT: A 16-year-old boy was referred to our ophthalmology clinic with a complete isolated bilateral horizontal gaze palsy. The condition had onset suddenly 2 weeks prior and he had no associated symptoms, as well as no significant medical history. His corrected visual acuity was 0.0 logMAR in both eyes. While hospitalized, he was found infected with COVID-19. Subsequent brain MRI showed multiple lesions typical of a yet undiagnosed MS, as well as an active pontine plaque which was highly probable the cause of the horizontal gaze palsy. High-dose steroid treatment was initiated 1 week later, after the patient exhibited negative COVID-19 test results. CONCLUSION: Clinical manifestations of MS are rarely seen in male teenagers and only a few cases of isolated bilateral horizontal gaze palsy have been reported as the initial manifestation, but never during concomitant COVID-19 infection. We presume that the presence of COVID-19 may have been a neuroinflammatory trigger of underlying MS.

Multiple Cranial Neuropathies After COVID-19 Vaccination

Objective: To present a patient with acute-onset of multiple cranial neuropathies associated with recent COVID-19 vaccination. Background: Vaccine-associated neurologic adverse effects have been well-described over the decades;the influenza vaccine as well as others have been thought to precede Guillain-BarréSyndrome (GBS), Miller-Fisher Syndrome (MFS), and similar processes. Hyper-inflammatory responses have been frequently reported with SARS-CoV-2 infection and immunization, along with various neurologic pathologies. In this case report we describe a cranial polyneuropathy (3, 6, 7 and 12) associated with the COVID-19 vaccine. Design/Methods: Case Report with Video/Photos Results: A 52-year-old R-handed female presented with acute-onset, rapidly progressive deficits including left upper lid ptosis, left eye ophthalmoplegia, leftward tongue deviation, left facial paresis and dysarthria. History includes congenital left eye cataract s/p lens exchange, remote strabismus surgery and slight ptosis at baseline. She denied recent illness or injuries, though had completed single-dose vaccination for SARSCoV-2 11 days prior to symptom onset. Exam revealed new L eye esotropia with restriction in abduction and supraduction. Also noted was worsening of baseline ptosis, weak tongue protrusion with right-sided fasciculations and leftward deviation. Patient endorsed dysphagia and dysarthria. Workup consisted of three unexplanatory MRIs during week of symptom onset, lumbar puncture, evaluation by ENT and neuro-ophthalmology as well as other serum and CSF studies to investigate other autoimmune causes. Consent-obtained videos and photographs were taken for documentation/educational purposes. Follow-up visits revealed slow improvement starting three months after symptom onset. Conclusions: We outline a case of a female patient who presented with progressive, multiple cranial neuropathies with onset 11 days after single-dose SARS-CoV-2 vaccination. This constellation of symptoms in the setting of COVID-19 vaccination suggests propensity towards autoimmune neurologic processes. Further investigation is needed to determine the true incidence of similar polyneuropathies with the COVID-19 vaccine and to guide providers and patients to make informed decisions.

Tele-Neuro-Ophthalmology: An Update One YearInto The COVID-19 Pandemic

Objective: This study evaluates the usage of tele-neuro-ophthalmology one year into the pandemic. Background: Tele-neuro-ophthalmology emerged as a resource early in the COVID-19 pandemic. Since then, telehealth utilization has evolved. Design/Methods: Telehealth utilization pre-COVID-19, early pandemic (March, 2020), and 1 year later (March, 2021) was surveyed among practicing neuro-ophthalmologists in and outside the United States using an online platform. Demographics, utilization, perceived benefits, barriers, and data utility opinions were collected over a two-week period in May 2021, prior to the emergence of the Delta and Omicron variants. Results: 135 practicing neuro-ophthalmologists (81.5% United States, 47.4% females) participated in the survey. One year into the pandemic, the proportion of respondents utilizing video telemedicine (50%) decreased from early-pandemic rates (65%) (p<0.0005, McNemar), but was sustained above pre-pandemic percentages (6%, p<0.0005, McNemar). 82% of current video users plan to continue video visits. Proportion of respondents using remote testing (42.2% vs 46.2%, p=0.45), virtual second opinions (14.5% vs 11.9%, p=0.38), eConsults (13.5% vs 16.2%, p=0.25), online portal communications, and remote interpretation of patient-submitted testing remained similar between March 2020 and 2021. The majority selected increased access to care, better continuity of care, and enhanced patient appointment efficiency as benefits, while reimbursement, liability, disruption of in-person clinic flow, limitations of video exams, and patient technology use were barriers. Many neuro-ophthalmic exam elements were deemed more suitable collected in a separate in-person visit rather than during a live video session, although respondents felt some exam components could be evaluated adequately via a virtual platform. Conclusions: One year into the COVID-19 pandemic yet prior to the emergence of the Delta and Omicron variants, neuro-ophthalmologists have maintained telemedicine utilization at rates higher than pre-pandemic levels. Tele-neuro-ophthalmology remains a valuable tool in augmenting patient care.

IMPROVING SERVICE PROVISION FOR PATIENTS WITH SUSPECTED IDIOPATHIC INTRACRANIAL HYPERTENSION IN A JOINT NEURO-OPHTHALMOLOGY CLINIC

Introduction Care of patients with suspected Idiopathic Intracranial Hypertension (IIH) involves neurolo-gists and ophthalmologists, however this can be difficult to co-ordinate. Consensus guidelines suggest all patients with suspected IIH should have weight, visual fields, neuroimaging and a CSF opening pressure. The aim of our study was to determine adherence to consensus guidelines. Methods We assessed medical notes of consecutive patients attending the new joint neuro-ophthalmol-ogy clinic in the Great Western Hospital, Swindon between 1st September'31st December 2020. Due to the Covid-19 pandemic a neurologist was not always present. Results Of 38 patients attending the clinic with suspected IIH, 35(92%) were female. 29(76%) had weight recorded;14 (37%) patients had BMI recorded, 12(32%) had BP recorded;36(95%)had visual fields recorded, 12(32%) and 17(45%) respectively had whether neuroimaging or lumbar puncture were required. 23(61%) had weight management discussed, 22 (58%) had a medication review discussed. Conclusion Documentation of weight, BMI, BP, investigation results and management discussions could be improved in the joint neuro-ophthalmology clinic. We aim to address this by introducing an 'IIH clinic checklist' for use by clinicians and patients to help improve adherence to consensus guidelines.

Post-COVID Wernicke's presenting as bilateral vision loss.

PURPOSE: This case report represents poor nutritional intake and vomiting secondary to COVID-19 resulting in Wernicke's syndrome and blindness. OBSERVATIONS: We report the case of a 36 year old with a post-COVID episode of acute-subacute onset bilateral blindness ultimately diagnosed as Wernicke's syndrome based on MRI findings and clinical response to high dose IV thiamine supplementation. CONCLUSIONS AND IMPORTANCE: Given this patient's dramatic presentation of no light perception vision in both eyes and resolution of symptoms with treatment, it is reasonable to consider thiamine deficiency in any individual who presents with acute-subacute onset vision loss, particularly when the history is suggestive of potential nutritional deficiency.

How to Manage a Strabismus Clinic During the COVID-19 Pandemic; What is Really Urgent, What is Not?: A Single-Center Case Series from Turkey

Objectives: To evaluate the management of the pediatric ophthalmology and strabismus clinic when strict quarantine conditions were adopted during the coronavirus disease 2019 (COVID-19) pandemic in Turkey. Materials and Methods: The study presents a review of the patients examined during the quarantine period. All patients were assessed with the highest possible level of personal protection. Results: Ten patients (6 girls, 4 boys) with a mean age of 9 years (range: 2-16) were evaluated. The patients presented 3-20 days after symptom onset. Ocular misalignment and diplopia were the main symptoms. Four of the 10 patients were diagnosed with sixth cranial nerve palsy and three patients were diagnosed with acute-onset comitant esotropia. Six patients had significant cranial magnetic resonance imaging findings. Conclusion: Acute-onset neurological conditions are more common during the COVID-19 pandemic. These reports will contribute to global experience and understanding of COVID-19.

Chapter 8 - Tele-Neuro-Ophthalmology

Tele-neuro-ophthalmology has gained significant adoption worldwide since 2020, largely precipitated by the COVID-19 pandemic. This trend may improve access to neuro-ophthalmic care, which is a scarce resource. Evaluation of many neuro-ophthalmologic conditions may benefit from telehealth due to their reliance on patient history and ancillary testing and less dependence on the physical exam. Formalized asynchronous telehealth modalities such as interprofessional consultation may allow neuro-ophthalmologists to provide rapid point-of-care advice to referring providers without the barrier of long referral wait times. There are multiple techniques and applications available to aid the evaluation of the neuro-ophthalmic patient. Deep machine learning algorithms may also eventually supplement neuro-ophthalmic care.

Simultaneous new onset of neuromyelitis optica spectrum disorder in identical twins.

OBJECTIVE: To present a case of two identical twins presenting concurrently with symptoms and subsequent initial diagnosis of neuromyelitis optica spectrum disorder (NMOSD). METHODS: Clinical, laboratory and MRI findings for both twins were reviewed and presented here. RESULTS: Twin A presented with right eye pain and subsequent blurred vision in right eye. MRI of the brain and spine demonstrated pre-chiasmal right optic nerve enhancement and T2 hyperintense lesions in the spinal cord at T7 and T9 levels. Cerebrospinal fluid (CSF) analysis was remarkable for NMO/aquaporin-4 (AQP4) fluorescence-activated cell sorting (FACS) titre of 1:32 and a serum NMO/AQP4-IgG positive titre of 1:10 000. Twin B presented with diplopia. MRI of the brain and spine demonstrated T2 hyperintense lesions in the periventricular cerebral white matter, in the periaqueductal white matter of the pons, in the midbrain and the cervical spinal cord. Neurological examination findings revealed incomplete right trochlear palsy, rotatory nystagmus, an incomplete left internuclear ophthalmoplegia and hyper-reflexia. CSF analysis was remarkable for NMO/AQP4 FACS titre of 1:256 and a serum NMO-IgG positive titre of 1:10 000. Both twins responded well to intravenous steroid therapy. There was no adverse environmental exposure present. CONCLUSION: We present an interesting and rare case of identical twins presenting concurrently and for the first time with NMOSD.

Tolosa-Hunt Syndrome Presenting After COVID-19 Vaccination.

Coronavirus disease 2019 (COVID-19) infection is associated with a plethora of neurological complications. Newly developed vaccinations targeting the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral spike protein represent a great epidemiological promise with respect to the resolution of the pandemic. However, vaccinations are not without side effects and, in rare cases, have even been implicated in various autoimmune phenomena. In this report, we describe a case of Tolosa-Hunt syndrome (THS), a granulomatous inflammatory process of the cavernous sinus, occurring in a patient one week after getting COVID-19 vaccination. This rare diagnosis of exclusion must be considered in patients presenting with painful ophthalmoplegia.

Unilateral inferior altitudinal visual field defect related to COVID-19.

Ocular manifestations of COVID-19 are still being studied. Posterior segment involvement in viral entities is either direct viral involvement or a delayed immune response to the antigen. A 22-year-old woman presented with history of perceiving absolute inferior scotoma in the right eye for 4 days and history of fever and sore throat 10 days ago. Fundus examination revealed disc edema and vessel tortuosity. Humphreys Field Analyzer confirmed inferior field defect and Optical Coherence Tomography showed superior, nasal and inferior retinal nerve fiber layer thickening in the right eye. Patient was positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by reverse transcription polymerase chain reaction (RT-PCR) testing. Patient received three doses of injection methylprednisolone over 3 days. There was subjective resolution of scotoma reported 3 weeks posttreatment. We bring forward the first reported case of parainfectious optic neuritis associated with COVID-19.