Neuro-Ophthalmic Visual Impairment in the Setting of COVID-19.

We set out to describe in detail the afferent neuro-ophthalmological complications that have been reported in association with coronavirus disease 2019 (COVID-19) infection. We describe and elaborate on mechanisms of disease, including para-infectious inflammation, hypercoagulability, endothelial damage, and direct neurotropic viral invasion. Despite global vaccination programs, new variants of COVID-19 continue to pose an international threat, and patients with rare neuro-ophthalmic complications are likely to continue to present for care.Afferent complications from COVID-19 include homonymous visual field loss, with or without higher cortical visual syndromes, resulting from stroke, intracerebral hemorrhage, or posterior reversible leukoencephalopathy. Optic neuritis has frequently been reported, sometimes along with acute disseminated encephalomyelopathy, often in association with either myelin oligodendrocyte glycoprotein antibodies (MOG-IgG) or less commonly aquaporin-4 seropositivity or in newly diagnosed multiple sclerosis. Ischemic optic neuropathy has rarely been reported. Papilledema, resulting either from venous sinus thrombosis or idiopathic intracranial hypertension in the setting of COVID-19, has also been described.Observed afferent neuro-ophthalmic associations need to be confirmed though larger comparative studies. Meanwhile, the range of possible complications should be recognized by neurologists and ophthalmologists alike, to facilitate faster diagnosis and treatment of both COVID-19 and its neuro-ophthalmic manifestations.

Development of an integrated telerehabilitation model in children with cerebral visual impairment in South India during the COVID-19 pandemic - A pilot study.

Purpose: Coronavirus disease 2019 (COVID-19) pandemic affected the in-person rehabilitation/habilitation services in families with children with cerebral visual impairment (CVI) in India. This study aimed to develop a structured and family-centered telerehabilitation model alongside conventional in-person intervention in children with CVI to observe its feasibility in the Indian population. Methods: This pilot study included 22 participants with a median age of 2.5 years (range: 1-6) who underwent a detailed comprehensive eye examination followed by functional vision assessment. The visual function classification system (VFCS) was administered to the children and the structured clinical question inventory (SCQI) to the parents. Every participant underwent 3 months of telerehabilitation including planning, training, and monitoring by experts. At 1 month, the parental care and ability (PCA) rubric was administered to the parents. After 3 months, in an in-person follow-up, all the measures were reassessed for 15 children. Results: After 3 months of Tele-rehabilitation there were significant improvements noted in PCA rubric scores (P<0.05). Also, statistically significant improvements were noted in functional vision measured using SCQI and VFCS scores (P<0.05) compared to baseline. Conclusion: The outcomes of the study provide the first steps towards understanding the use of a novel tele-rehabilitation model in childhood CVI along-side conventional face-to-face intervention. The added role of parental involvement in such a model is highly essential.

The 20/20/20 rule: Practicing pattern and associations with asthenopic symptoms.

Purpose: The present work style and lifestyle have increased the digital device use. Therefore, an increase in digital eyestrain is to be expected. We undertook a survey during coronavirus disease 2019 (COVID-19) pandemic to investigate the practice of 20/20/20 rule and its association with digital device use and asthenopic symptoms. While this rule is commonly advised, little is known about its validity. Methods: An online survey form was disseminated through social media and emails. The questions for eye-related symptoms were similar to the convergence insufficiency symptom survey (CISS). Participants with age ≥5 years were included, with parents completing the survey for children (≤16 years). Results: A total of 432 participants (mean ± standard deviation [SD]: 26.06 ± 13.92 years) were enrolled, of which 125 responses were for children. The 20/20/20 rule was practiced only by 34% of the participants either regularly (n = 38) or occasionally (n = 109). Those who had complaints of burning sensation and headache tended to practice this rule. Among adult participants, more females (47%) practiced this rule when compared to males (23%). Also, adult females significantly (P = 0.04) had more symptoms score when compared to males. In children, no such gender difference was found. Conclusion: Only one-third of participants practice the 20/20/20 rule at least occasionally. More number of adult females being symptomatic and practicing in greater number could be due to higher prevalence of dry eye condition in females. While the symptom of burning sensation could be related to dry eye, that of headache could be related to refractive error or binocular vision dysfunctions.

Headache, Loss of Smell, and Visual Disturbances: Symptoms of SARS-CoV-2 Infection? A Case Report.

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.

Visual fields in glaucoma: Where are we now?

Visual fields are an integral part of glaucoma diagnosis and management. COVID has heightened the awareness of the potential for viral spread with the practice of visual fields modified. Mask artefacts can occur due to fogging of the inferior rim of the trail lens. Fortunately, the risk of airborne transmission when field testing is low. The 24-2c may be useful to detect early disease and the 10-2 more sensitive to detect advanced loss. The SITA faster test algorithm is able to reduce testing time thereby improving clinic efficiency, however, may show milder results for moderate or severe glaucoma. The technician has an important role of supervising the visual field performance to achieve reliable output. Home monitoring can provide earlier detection of progression and thus improve monitoring of glaucoma as well as reduce the burden of in-clinic assessments. Artificial Intelligence has been found to have high sensitivity and specificity compared to expert observers in detecting field abnormalities and progression as well as integrating structure with function. Although these advances will improve efficiency and guide accuracy, there will remain a need for clinicians to interpret the results and instigate management.

Inferior altitudinal visual loss and mask-wearing practices: A case series.

Face mask-wearing practices and their impact on the visual field bear particular importance in the coronavirus disease 2019 (COVID-19) pandemic era. This case series examines 10 participants with no history of ocular impairment or visual field defects who underwent age-corrected visual field testing in both eyes with different types of face masks. Wearing duckbill N95 masks was consistently associated with increased accuracy errors in the inferior altitudinal visual field when compared to wearing surgical masks or no masks. These findings support public health guidance that has previously attributed the risks of falls and accidents to face mask wearing.

Acute Unilateral Central Serous Chorioretinopathy after Immunization with Pfizer-BioNTech COVID-19 Vaccine: A Case Report and Literature Review.

INTRODUCTION: A 43-year-old Caucasian male presented to our ophthalmology clinic with blurry vision and metamorphopsia in his right eye, 24 hours after receiving the first dose of the Pfizer-BioNTech COVID-19 vaccine. METHODS: Clinical examination and imaging tests were consistent with acute unilateral central serous chorioretinopathy (CSCR) that completely resolved after 2 months without any treatment. He had no significant ophthalmic or medical history. He also lacked the classical risk factors for CSCR such as recent psychosocial stressors, Type-A personality traits, history of exogenous steroid use, connective tissue disorders and obstructive sleep apnea. RESULTS: This appears to be only the second reported case of CSCR, temporally associated with a recombinant COVID-19 mRNA vaccine. We also present a summary of published reports demonstrating intraocular complications associated with the novel recombinant COVID-19 mRNA vaccines. CONCLUSION: Findings in this report should not deter COVID-19 vaccinations given the rarity of aforementioned ocular complications and the greater benefit of protection from COVID-19 infection. Medical practitioners, however, should remain mindful of potential ocular complications, given the greater likelihood of occurrence with increasing vaccination booster rates.

A Case of Transient Visual Field Defect following Administration of Pfizer-BioNTech COVID-19 Vaccine.

PURPOSE: To report a case of transient visual field (VF) defect after coronavirus disease-19 (COVID-19) vaccination. CASE REPORT: A 38-year-old Caucasian, otherwise healthy female patient, presented with a complaint of vision loss in the outer quadrant in her left eye after the second dose of Pfizer®-BioNTech™ COVID-19 vaccine. The Snellen visual acuity was 20/20 in both eyes. She did not have relative afferent pupillary defect nor disturbance of color vision. Her intraocular pressures, slit lamp and fundus examinations were normal. In the VF test, a temporal hemifield defect in the left eye and a nasal peripheral VF defect in the right eye were detected. Other imaging characteristics and neurological examination were normal. She was followed without any treatment. One week later, the patient was re-evaluated and complete resolution of the VF defect was observed. CONCLUSION: Clinicians should be aware that patients can experience transient visual symptoms following COVID-19 vaccination.

Clinico-Radiological-Pathological Correlation of Visual Loss in COVID-Associated Rhino-Orbito-Cerebral Mucormycosis.

PURPOSE: To correlate the clinical, radiological, and histopathological features in Covid-associated Rhino-orbito-cerebral mucormycosis cases presenting with acute visual loss. DESIGN: Cross-sectional study. METHODS: Covid-associated Rhino-orbito-cerebral mucormycosis cases with unilateral visual loss, planned for exenteration, underwent orbital and ophthalmological ocular examination. The available radiological sequences, doppler ultrasonography and histopathology findings were correlated with clinical manifestations. RESULTS: The median age was 51 years and the male: female ratio was 3:1. All except one presented with unilateral ophthalmoplegia. The ocular media were hazy in 2 eyes. In 8 eyes, retinal changes were suggestive of occlusion of CRA (6), combined occlusion of CRA and central retinal vein (1), and myopic degeneration with hypertensive retinopathy (1). The contralateral eye showed retinal ischemic changes in one patient. Radiological imaging showed orbital apex involvement in the 10 affected eyes and one contralateral eye. Ipsilateral cavernous sinus thrombosis, diffusion restriction on MRI of optic nerve, internal carotid artery narrowing/thrombosis, and cortical watershed infarcts were seen in 8, 4, 4, and 2 cases, respectively. The blood flow in CRA and ophthalmic artery was absent or reduced in all the 10 affected eyes and in 1 contralateral eye. On histopathology, orbital fat necrosis, fungal hyphae, acute inflammation, granuloma formation, ischemic thrombosis of ophthalmic artery was observed in 10 specimens. CRA was patent in 9 and thrombosed in 1 eye. Optic nerve was ischemic in 8 and viable in 2 eyes. CONCLUSION: Acute visual loss in ROCM cases is associated with orbital apex involvement and thrombotic ischemia of ophthalmic artery. Cessation of flow in CRA possibly occurs secondary to ophthalmic artery thrombosis.

Pediatric Intracranial Hypertension: A Spotlight on Imaging, the Idiopathic Intracranial Hypertension Treatment Trial, and COVID-19 Associated Cases.

Primary intracranial hypertension (PIH) is characterized by clinical signs of increased intracranial pressure, papilledema, elevated opening pressure, and absence of mass lesion, hydrocephalus, or meningeal enhancement on neuroimaging. Visual changes are a common presenting feature and if untreated there is risk of irreversible vision loss. There have been recent proposed changes to the criteria for PIH along with studies looking at the differences in imaging characteristics between adult and pediatric PIH. The presence of transverse sinus stenosis alone was highly sensitive and specific for pediatric PIH. The Idiopathic Intracranial Hypertension Treatment Trial was an adult, multicenter study that examined the use of acetazolamide and weight loss on the course of PIH. The study confirmed many previously held beliefs including the most common presenting symptom in PIH is headache. Most patients present with bilateral papilledema with 58.2% of patients having symmetric Frisen scale grading and within one grade in 92.8%. Although diplopia is a common reported symptom, very few have evidence of cranial nerve palsy. Male gender, high-grade papilledema, and decreased visual acuity at presentation are risk factors for treatment failure. Acetazolamide use is associated with mild metabolic acidosis. During acetazolamide treatment, monitoring for hypokalemia or aplastic anemia is not recommended. Monitoring transaminases in the titration phase of treatment should be considered due to a case of transaminitis and pancreatitis with elevated lipase. Newer case reports have also seen associations of secondary intracranial hypertension with concurrent COVID-19 infection and MIS-C.

Intracranial hypertension and visual loss following COVID-19: A case report.

A 40-year-old woman presented with headache, bilateral optic disc edema, and visual loss. She had been diagnosed with COVID-19 (coronavirus disease 2019) 15 days ago. Her cerebrospinal fluid opening pressure was 410 mmH2O, and cranial imaging was normal. She had obesity as a risk factor but had not experienced any ophthalmic complaints before. COVID-19 could be a causative or precipitating factor for intracranial hypertension especially in high-risk groups even in the late phases of the disease and has not been discussed in the literature as such. This should be studied further and kept in mind to prevent permanent loss of vision.

Acceptability of a home-based visual field test (Eyecatcher) for glaucoma home monitoring: a qualitative study of patients' views and experiences.

OBJECTIVES: To explore the acceptability of home visual field (VF) testing using Eyecatcher among people with glaucoma participating in a 6-month home monitoring pilot study. DESIGN: Qualitative study using face-to-face semistructured interviews. Transcripts were analysed using thematic analysis. SETTING: Participants were recruited in the UK through an advertisement in the International Glaucoma Association (now Glaucoma UK) newsletter. PARTICIPANTS: Twenty adults (10 women; median age: 71 years) with a diagnosis of glaucoma were recruited (including open angle and normal tension glaucoma; mean deviation=2.5 to -29.9 dB). RESULTS: All participants could successfully perform VF testing at home. Interview data were coded into four overarching themes regarding experiences of undertaking VF home monitoring and attitudes towards its wider implementation in healthcare: (1) comparisons between Eyecatcher and Humphrey Field Analyser (HFA); (2) capability using Eyecatcher; (3) practicalities for effective wider scale implementation; (4) motivations for home monitoring. CONCLUSIONS: Participants identified a broad range of benefits to VF home monitoring and discussed areas for service improvement. Eyecatcher was compared positively with conventional VF testing using HFA. Home monitoring may be acceptable to at least a subset of people with glaucoma.

Neuro-ophthalmologic complications of coronavirus disease 2019 (COVID-19).

Multiple neuro-ophthalmological manifestations have been described in association with COVID-19. These symptoms and signs may be the result of a range of pathophysiological mechanisms throughout the course from acute illness to recovery phase. Optic nerve dysfunction, eye movement abnormalities and visual field defects have been described.