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Purpose/Relevance: Pediatric cases of COVID-19 have increased in the setting of the highly transmissible delta variant which has impacted the care of children by ophthalmologists. Inflammatory ocular manifestations of acute COVID-19 infections have been observed and are important to recognize and expeditiously manage. Further, ocular involvement has been recognized in MIS-C. Finally, new challenges in treating and monitoring patients with non-infectious uveitis (NIU) evolved. Guidance is needed regarding immunosuppression, reducing clinic visits/in-hospital exposures while maintaining disease control, and vaccination. Target Audience: Pediatric ophthalmologists, fellows, residents. Current Practice: Ocular inflammatory manifestations are reported in children during or after symptomatic or asymptomatic COVID-19 infection and may go unrecognized. Guidelines for managing children with NIU on immunosuppressive treatment (IMT) continues to evolve, and updated information is needed. Best Practice: Knowledge of ocular manifestations of acute and post-infectious COVID-19 including Multisystemic Inflammatory Syndrome in Children (MIS-C) will improve clinical care of children. Patients may present with conjunctivitis, optic neuritis, transient myasthenia-like syndrome, acute anterior uveitis, keratitis, pan-uveitis and papilledema. Ophthalmic management often involves systemic work-up and coordination of care amongst a multidisciplinary team. Consensus guidelines for monitoring uveitis and preventing COVID-19 infection in children with NIU on IMT may be applied to clinical practice. Expected Outcomes: Clinicians will develop an understanding of (1) Ophthalmic manifestations of acute and post-infectious COVID-19 infection and MIS-C (2) Challenges and strategies to manage NIU during a pandemic (3) Updates on infection risk and vaccination strategies for children on IMT. Format: Didactic, case presentations, rheumatology, ophthalmology panel discussion with audience participation. Summary: COVID-19-related ocular manifestations such as conjunctivitis, uveitis, pan-uveitis and optic neuritis are rare but are important to recognize. Children with NIU on IMT represent a unique patient population balancing ophthalmic follow-up and control of ocular/systemic disease and preventing infection.Copyright © 2022
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Background: Severe acute respiratory syndrome coronavirus 2 (SARSCoV2) has been associated with several neuro-ophthalmic manifestations. We report a case of bilateral longitudinally extensive optic perineuritis suspected due to SARSCoV2. Case Presentation: A 32-year-old woman developed headaches, photophobia, pulsatile tinnitus, and blurred vision 8 d after having a positive SARS-CoV-2 qualitative polymerase chain reaction (PCR) testing for coronavirus disease 2019 (COVID-19). She was diagnosed with and treated for idiopathic intracranial hypertension (IIH) elsewhere. Repeat evaluation at our institution showed a poor visual acuity in both eyes with Frisen grade II papilledema and cotton wool spots on fundoscopic examination. Orbital magnetic resonance imaging (MRI) showed bilateral longitudinally extensive optic nerve sheath enhancement. Repeat lumbar puncture revealed an elevated cerebrospinal fluid (CSF) opening pressure and protein, a finding that is incompatible with the diagnosis of IIH. Myelin oligodendrocyte glycoprotein, aquaporin-4 (AQP4)-IgG antibodies, and other serological tests for optic neuritis were unremarkable. Her visual acuity partially improved after corticosteroids. With the growing association of demyelinating disorders and COVID-19, unremarkable serological workup, and temporal relation of the patient's symptoms to the infection, we believe that her diagnosis is SARS-CoV-2 associated bilateral optic neuritis. Conclusion(s): There is a growing association between demyelinating disorders and COVID-19 and COVID-19 vaccination, and it is essential to recognize CSF abnormalities that are incompatible with a diagnosis of IIH, such as increased protein in our case, and may lead to an incorrect diagnosis.Copyright © 2023 The Authors. Clinical and Experimental Neuroimmunology published by John Wiley & Sons Australia, Ltd on behalf of Japanese Society for Neuroimmunology.
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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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OBJECTIVE: The purpose of this case report is to describe the main components of the history and physical examination that led to idiopathic intracranial hypertension differential diagnosis, which initially was investigated as COVID-19. METHODS (CASE DESCRIPTION): A 28-year-old woman complaining of constant headache and loss of smell and taste was suspected as SARS-CoV-2 infection by her general practitioner. She underwent 3 molecular swab tests, all negative, then decided to seek her physical therapist for relieving headache. RESULTS: The full cranial nerve examination revealed impaired olfactory (CNI), abducens (CN VI), and facial (CN VII) nerves, leading the physical therapist to refer the patient to a neurosurgeon for a suspected central nervous system involvement. The neurosurgeon prescribed a detailed MRI and an ophthalmologic examination, which allowed for the final diagnosis of idiopathic intracranial hypertension. CONCLUSION: An urgent lumbo-peritoneal shunting surgery resolved the patient's symptoms and saved her sight. Despite the ongoing COVID-19 pandemic, health care professionals must pay attention to properly investigating patients' signs and symptoms using comprehensive clinical reasoning, considering the screening for referral to specialist medical attention. IMPACT: A thorough physical examination is required for every patient even if patients' signs and symptoms are in line with apparent common and widespread pathologies. Cranial nerve evaluation is an essential component of the physical therapist assessment and decision-making process. The ongoing pandemic highlighted the fundamental assistance of physical therapists toward physicians in the screening and management of musculoskeletal diseases.
Subject(s)
COVID-19 , Papilledema , Pseudotumor Cerebri , Humans , Female , Adult , Pseudotumor Cerebri/diagnosis , Pseudotumor Cerebri/surgery , Papilledema/diagnosis , Papilledema/etiology , Papilledema/surgery , Anosmia/complications , Pandemics , COVID-19/complications , SARS-CoV-2 , Vision Disorders/diagnosis , Vision Disorders/etiology , Headache/diagnosis , Headache/etiologyABSTRACT
Background: Neurological autoimmune disorders are often triggered by bacterial and viral infections, with growing evidence supporting coronavirus disease 2019 (COVID-19) infection precipitation of these disorders. COVID-19 is already implicated in causing discrete para-infectious neurological syndromes: acute disseminated encephalomyelitis (ADEM), transverse myelitis, neuromyelitis optica spectrum disorders (NMOSD), Guillain-Barre syndrome (GBS), and is also associated with encephalopathy, acute cerebrovascular disease, neuromuscular disorders, and seizures. Case Presentation: We describe a case of a 43-year-old Asian woman with chronic Hepatitis B (HBV) co-infected acutely with COVID-19, presenting with urinary retention, bilateral blindness, thoracic sensory level, and quadriparesis. Extensive workup narrowed down her diagnosis as seronegative NMOSD. She had complete resolution of symptoms after treatment with concurrent plasma exchange (PLEX), high dose corticosteroids, and emtricitabine-tenofovir. Follow-up visit showed no seroconversion at 6 months and no relapses. Conclusion(s): Our literature review highlights the likely link between COVID-19 infection and the development of neurologic autoimmune diseases. Our literature review supports a virus-triggered immune-mediated process rather than neuro-invasion. Many viral illnesses have been linked to the development of NMOSD and anti-AQP4 antibody-related myelitis. Additionally, there is limited literature linking chronic HBV infection with the development of optic neuritis and speculation thatcross-reactivity between HBsAg and myelin antigens may lead to the development of demyelinating diseases in the CNS and PNS. We observed remarkable clinical improvement after treatment with alternating days of IV methylprednisolone and therapeutic PLEX.Copyright © 2022
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Mild encephalitis/encephalopathy with a reversible lesion in the splenium (MERS) is a clinico-radiological syndrome with mild central nervous system symptoms and a reversible lesion in the splenium of the corpus callosum. It is mainly associated with a number of viral and bacterial infections, including Coronavirus disease 2019 (COVID-19). In this paper, we report four MERS patients. One had a mumps infection, the second had aseptic meningitis, the third had Marchiafava-Bignami disease, and the fourth had atypical pneumonia associated with COVID-19 infection.
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BACKGROUND: Bilateral papilledema with vision loss is considered a neurosurgical emergency due to high intracranial pressure. However, it may not be the only cause of papilledema. The authors reported an association among coronavirus disease 2019 (COVID-19), bilateral papilledema, blindness, and Wernicke's encephalopathy (WE). OBSERVATIONS: An 18-year-old woman presented to the neurosurgery service with rapid profound vision loss and bilateral papilledema. She had COVID-19 3 months earlier with subsequent loss of smell (anosmia) and taste (ageusia), which resulted in hyperemesis and a 43-lb weight loss. Examination revealed ataxia, horizontal nystagmus, and blindness. Magnetic resonance imaging and magnetic resonance venography of her brain were normal. Presumptive diagnosis of WE was made, and she was treated with intravenous thiamine with restoration of vision within 48 hours. Patient's thiamine level was less than half the normal value. LESSONS: Neurosurgeons should be aware of this unique correlation between papilledema and vision loss and its association with WE due to post-COVID-19 hyperemesis and weight loss from anosmia and ageusia.
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Objective: To determine association of papilledema with headache using 20D lens and a smartphone for fundoscopy. Study Design: Prospective Cross-sectional Study Place and Duration of Study: This study was conducted at the Ophthalmology OPD at Liaqat National Hospital, Karachi from, 25th May 2022 till 25th July 2022. Materials and Methods: Patients, presenting to ophthalmology OPD at Liaqat National Hospital, patient complaining of blurring of vision and difficulty focusing on distant object were included in our study. We used a 20D lens for indirect ophthalmoscopy and smartphone camera for recording and taking pictures. Participant's pupils were dilated using 1% tropicamide drops and waited for 15-20 mins for pupil dilation. Video recording was done with flashlight switched on and recording was reviewed for fundus pictures and snap shots were taken from it. Results: 384 patients were included in the study. There were 65.6% male and 34.4% female patients in our study with mean age 41.93±13.50 years while majority (62.8%) were from age group >35 years. we found 3.6% of patients with obesity, 12.2% with diabetes mellitus, 14.3% with hypertension and 45.1% with headache and 7.3% of patients were found with papilledema. Strong association was found with papilledema and headache with p-value of <0.001. Conclusion: Strong association of papilledema with headache was found in patients who came with symptoms of blurry vision and We can reliably do fundus visualization with Smartphone based indirect ophthalmoscopy to view optic disc for presence of papilledema, can be cheap alternative to conventional ophthalmoscopy devices even in neurosurgical examinations, in covid-19 era where social distancing is a norm and proximity to the patients with direct ophthalmoscopy can be discomforting in these circumstances. © 2022 Medical Forum Monthly. All rights reserved.
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Background and aims: Idiopathic Intracranial Hypertension (IIH) is caused by elevated cerebrospinal fluid pressure of unknown aetiology predominantly affecting obese women of childbearing age. This study looked into the management of this patient population in a country with a rising obesity rate. Methods: Patients diagnosed with IIH were identified through the national Maltese database and further data was retrospectively collected from patients' files. Results: 59 patients were identified with an average age of 34 (14-68yr), and BMI 36.3 (26.7-49.1). Most underwent repeated lumbar punctures (Graph 1). The average opening pressure was 31.71cm of water (17-72cm of water). Visual field testing (75%), fundal photos (44%) and optical coherence tomography (21%) were often employed to assess papilledema. MRI showed typical IIH changes in 75% (Table 1). All patients were started on acetazolamide. Magnitude and specific strategies for weight loss were not routinely documented. 17% were offered surgical management;including shunt insertion (15%), and dural venous sinus stenting (5%). (Figure Presented) Conclusion: With rising obesity rates, this has become an increasingly prevalent disorder. Moreover, several patients either presented or relapsed following weight gain at the beginning of the COVID-19 pandemic. This study confirmed that more focus should be employed towards weight loss, which was often poorly documented and not aggressively targeted. Patients were undergoing frequent lumbar punctures rather than repeat, non-invasive ophthalmological investigations - this was tackled locally by involving an ophthalmologist with a special interest in the disorder. A multidisciplinary task force and new local guidelines have been instrumental in standardising and optimising management for these patients.
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A cilioretinal artery occlusion (CLRAO) associated with optic disc edema was diagnosed in a patient seven days after the second dose of viral vector SARS-CoV-2 vaccination. The patient developed sudden blurred vision in the inferior hemifield of the right eye. His fundus examination showed retina edema at the superotemporal quadrant within vascular arcades of the right eye. Fundus fluorescein angiography (FFA), optical coherence tomography (OCT), and optical coherent tomography angiography (OCTA) were used to confirm the diagnosis.
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Background Enforced national lockdown due to COVID-19 limited access to medical services. We evaluated the impact on those presenting with papilloedema, and those with a preexisting diagnosis of idiopathic intracranial hypertension. Design A single United Kingdom centre prospective cohort study between May 15, 2020 (start of emergency clinics after first 8 week national lockdown) and July 31, 2020. Demographics, diagnosis and outcomes were documented. Results The study recorded 130 individual patients, 123 with a diagnosis of idiopathic intracranial hyper-tension. 92% were female and mean age was 32.5 years. Emergency cerebrospinal fluid diversion surgery was required in 13% (17/130), a 4.7-fold (367%) increase compared to the same period in 2019. Weight increased in 58% (mean 6.2kg SD 4.6) and corresponded to a significant increase in papilloedema (Optical Coherence Tomography retinal nerve fibre layer 15mm SD 57.3, p=0.014). Elevated anxiety levels (hospital anxiety and depression scale >7) occurred in 64%. Conclusions There was a 367% increase in emergency shunting to save vision in idiopathic intracranial hypertension following national lockdown. Worsening of papilloedema, weight gain, and detrimental effects on mental health were recorded. Countermeasures should be implemented to minimise harm in this rare disease during future service restrictions and lockdowns.
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Coronavirus disease-19 (COVID-19) patients are at an increased risk of cerebral venous sinus thrombosis (CVST). Rapid diagnosis and treatment are vital to ensure a favorable outcome for CVST, so clinicians need to be aware of all its potential presentations. We describe a unique case where transient visual obscurations (TVOs) from papilledema were the presenting symptoms of COVID-19-related CVST. A 43-year-old woman, who had tested positive for severe acute respiratory syndrome coronavirus-2 1 month earlier, developed holocephalic headache, TVOs, and bilateral disc edema. She did not seek medical attention until she developed TVOs. Visual acuity was 20/20 and Humphrey visual field testing showed enlarged blind spots in both eyes. She was diagnosed with papilledema and underwent magnetic resonance imaging and magnetic resonance venography of the brain, which revealed right transverse sinus thrombosis. Lumbar puncture was performed, showing elevated opening pressure and normal cerebrospinal fluid contents. Her optic disc edema resolved and visual function remained normal 6 weeks following warfarin and topiramate therapy. Recanalization of the right transverse sinus occurred after 3 months. Although rare, TVOs are important presenting symptoms of COVID-19-related CVST. Ophthalmologists, who may be the first physicians to assess patients with this presentation, should be aware of TVOs as potential presenting symptoms of CVST, so diagnoses can be made in a timely manner.
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Introduction: Many studies have shown that coagulation disorders and increased risk of thrombosis may occur during coronavirus disease 2019 (COVID-19) infection. Although cardiac or pulmonary vascular pathologies has been detected in most cases, cerebral sinus thrombosis are rare. During COVID-19 infection patients rarely present with neurological symptoms. Case Report: A 19-year-old man was admitted to our emergency department with neurological symptoms. Cerebral venous sinus thrombosis (CVST) was detected in Brain Computerized Tomography and Magnetic Resonance Imaging examinations. Our patient was hospitalized in the neurology department of our hospital for medical treatment and was discharged after clinical recovery. Discussion: In this case report we wanted to draw attention to cerebral venous sinus thrombosis which is a rare but treatable complication of COVID-19 infection in a young patient. We examined our patient in the light of literature. Conclusion: Clinicians should keep in mind the diagnosis of CVST that may occur due to infection associated thrombosis in COVID-19 patients presenting with neurological symptoms and consider adding anticoagulants to the treatment if necessary.
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The severity of coronavirus disease 2019 (COVID-19) has been frequently associated with acute respiratory distress syndrome. In this case report, an atypical presentation of COVID-19 in young with a thromboembolic event is reported. The patient initially presented with fever of unknown origin not responding to therapy. On examination, visual acuity was 20/20 in both eyes with bilateral disc oedema and disc haemorrhage in the right eye. Erythrocyte sedimentation rate, C-reactive protein and D-Dimer were elevated. Magnetic resonance venography (MRV) revealed features suggestive of cerebral venous thrombosis. Timely diagnosis and intervention have prevented a fatal outcome.