Phlyctenular Keratoconjunctivitis in a Patient With COVID-19 Infection.

ABSTRACT: The coronavirus disease 2019 global pandemic is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Several ophthalmic manifestations have been reported to be associated with SARS-CoV-2 infection, including conjunctivitis, acute sixth nerve palsy, and multiple cranial neuropathies. We present a unique case of unilateral phlyctenular keratoconjunctivitis in a 5-year-old boy in the setting of SARS-CoV-2 infection.

CHARACTERIZING COVID-19-RELATED RETINAL VASCULAR OCCLUSIONS: A Case Series and Review of the Literature.

PURPOSE: To describe clinical and ophthalmologic features and outcomes of patients with coronavirus disease-19 with retinal vascular occlusions. METHODS: Retrospective multicenter case series and PubMed review of cases reported from March 2020 to September 2021. Outcome measures are as follows: type of occlusion, treatments, best-corrected visual acuity, and central macular thickness on optical coherence tomography. RESULTS: Thirty-nine patients were identified. Fifteen patients with a median age of 39 (30-67) years were included in the multicenter study. Vascular occlusions included central retinal vein occlusion (12 eyes), branch retinal vein occlusion (4 eyes), and central retinal artery occlusion (2 eyes). Three cases were bilateral. Baseline best-corrected visual acuity was 20/45 (no light perception-20/20). Baseline central macular thickness was 348.64 (±83) µm. Nine eyes received anti-vascular endothelial growth factor agents, dexamethasone intravitreal implant, or both. Final best-corrected visual acuity was 20/25 (no light perception-20/20), and central macular thickness was 273.7 ± 68 µm (follow-up of 19.6 ± 6 weeks). Among the 24 cases from the literature review, retinal vein occlusion was the predominant lesion. Clinical characteristics and outcomes were similar to those found in our series. CONCLUSION: Coronavirus disease-19-associated retinal vascular occlusions tend to occur in individuals younger than 60 years. Retinal vein occlusion is the most frequent occlusive event, and outcomes are favorable in most cases.

Presbyopia developed earlier during the COVID-19 pandemic.

PURPOSE: The aim of this cohort study was to evaluate the development and progression of presbyopia and the status of dry eye-related symptoms from 2017 to 2020, to assess the impact of the COVID-19 pandemic. METHODS: Near add power at 30 cm was measured in 339 participants aged between 40 and 55 from 2017 to 2021 at Japanese eye clinics. Regression analysis of near add power and age was analyzed to compare 2017 with later years up to the pandemic. The prevalence of dry eye-related signs and six common symptoms were compared. RESULTS: The number and mean age (y) of participants were 183 (48.6±4.1) in 2017, 46 (51.3±7.5) in 2019, and 110 (49.2±3.7) in 2020-21, respectively. The mean progression rate of near add power (D/y) was 0.13 for 2017, 0.09 for 2019 (P = 0.028, vs 2017), and 0.08 for 2020-21 (P<0.001, vs 2017). The slope (rate of presbyopia progression) became flatter from 2017 to 2021 and the estimated near add power at the age of 40 increased from 2017 to 2020-2021, implicating presbyopia developed earlier and worsened during the study period. The 2017 values were comparable with previous studies described in 1922 and 2019. The standardized correlation coefficient between age and near add power was 0.816 for 2017, 0.671 for 2019 (P = 0.084, vs 2017), and 0.572 for 2020-21 (P<0.001, vs 2017). Multiple regression analysis revealed age and COVID-19 pandemic were significantly correlated with near add power. The prevalence of dryness irritation, and pain was greater in 2020-21 than in 2017 with no difference in the prevalence of eye fatigue, blurring, and photophobia. There was no difference in the prevalence of short tear break-up time and positive corneal staining among 2017, 2019 and 2020-21. CONCLUSION: Estimated presbyopia developed earlier and progressed slower from 2017 to 2021, the COVID-19 pandemic. Stress and rapid digitalization related to strict infection control and quarantine might be contributing factors.

Herpes Zoster Ophthalmicus After COVID-19 Vaccination: Chance Occurrence or More?

ABSTRACT: As the understanding of COVID-19 infection becomes better, it is being recognized as a complex multisystem pathology rather than just affecting the lungs. Several ocular findings have been documented by researchers in individuals infected with COVID-19, and ocular symptoms may even be the first presenting feature of COVID-19 infection in 2.26% individuals. Several countries have started vaccination with inactivated or live vaccines to combat this pandemic, and varied side effects have been reported after vaccination. Few cases of herpes zoster have previously been reported in elderly patients with comorbidities after receiving COVID-19 vaccines. In this article, the authors described 2 interesting cases of herpes zoster ophthalmicus (HZO) after receiving a live COVID-19 vaccine. The first case was a 35-year-old immunocompetent man who developed HZO 3 days postvaccine. The second case was a 40-year-old immunocompetent man who developed HZO 28 days postvaccine. To the best of our knowledge, no literature to date has described HZO after live vaccine.

First Clinical Experience With Ophthalmic e-Device for Unaided Patient Self-Examination During COVID-19 Lockdown.

PURPOSE: The aim of this study was to describe a new type of medical device that allows for internet-enabled patient self-screening, without the aid of an ophthalmic professional, through biomicroscopy self-imaging and self-measurement of the best-corrected visual acuity (BCVA). METHODS: In this prospective nonrandomized comparative study, 56 patients were instructed to screen their own eyes using a custom-built e-Device containing miniaturized slitlamp optics and a visual acuity Snellen chart virtually projected at 20 ft. BCVA measurements were recorded, and biomicroscopic videos were scored for image quality of the anterior segment status on a scale from 1 to 5 (1 = poor and 5 = excellent) by a blinded observer. RESULTS: After a short instruction, all patients were able to self-image their eyes and perform a self-BCVA measurement using the e-Device. Patient self-image quality with the e-Device scored on average 3.3 (±0.8) for videos (n = 76) and 3.6 (±0.6) for photographs (n = 49). Self-BCVA measurement was within 1 Snellen line from routine BCVA levels in 66 of 72 eyes (92%). When compared with conventional biomicroscopy, patient self-biomicroscopy allowed for recognition of the relevant pathology (or absence thereof) in 26 of 35 eyes (74%); 9 cases showed insufficient image quality attributed to device operating error (n = 6) and mild corneal edema and/or scarring (n = 3). Patient satisfaction with the device was 4.4 (±0.9). CONCLUSIONS: An e-Device for combined BCVA self-measurement and biomicroscopy self-imaging may have potential as an aid in remote ophthalmic examination in the absence of an ophthalmic professional and may be considered for patients who are unable to visit an ophthalmic clinic for routine follow-up.

IMPACT OF CORONAVIRUS DISEASE PANDEMIC ON INTRAVITREAL INJECTIONS TREATMENT FOR MACULAR DISEASES: Report From a Referral Hospital in Milan.

PURPOSE: To describe our managing strategy for COVID-19 emergency, to evaluate the adherence to intravitreal treatment (AtT) rate during the outbreak in a referral hospital in Milan, and to correlate it with patients' clinical features. METHODS: The AtT rate of patients with scheduled intravitreal injections during the COVID-19 outbreak from February 23, 2020 to March 31, 2020 was compared with the previous trimester and with March 2019. The impact of age, sex, visual function, and diagnosis on the AtT rate during unlocked/locked weeks (from March 8th) was evaluated. RESULTS: Of 650 consecutive patients with scheduled intravitreal injections, the AtT rate during the COVID-19 outbreak was 0.37. This was significantly lower compared with AtT registered in the previous trimester (0.92) and in the same weeks in 2019 (0.90) (both P < 0.001). Patients adherent to treatment were significantly younger (P < 0.001) and had a lower best-corrected visual acuity in the fellow eye (P = 0.046). During the lockdown weeks, the AtT rate was significantly lower than in the two unlocked weeks (0.19 vs. 0.73, P < 0.001). In addition, the AtT rate in patients classified as "emergent" during the lockdown weeks was 0.60. CONCLUSION: These preliminary results can help the retina specialist community to foresee this unique scenario and to develop successful management strategies.

Acute Corneal Epithelial Rejection of LR-CLAL After SARS-CoV-2 Vaccination.

PURPOSE: The purpose of this study was to report a case of acute corneal epithelial rejection of living-related conjunctival limbal allograft (LR-CLAL) after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. OBSERVATIONS: A 27-year-old woman developed acute epithelial rejection of LR-CLAL 2 weeks after receiving the SARS-CoV-2 vaccine. She received the LR-CLAL transplant 4 years and 7 months previously and had a stable clinical course with no history of rejection. She had an ABO blood group and human leukocyte antigen compatible donor, no systemic comorbidities, and no rejection risk factors. CONCLUSIONS: The novel SARS-CoV-2 vaccine upregulates the immune system to produce an adaptive immune response. The SARS-CoV-2 vaccine may potentially be associated with increased risk of rejection in those with ocular surface transplants.

Acute Corneal Transplant Rejection After COVID-19 Vaccination.

PURPOSE: The purpose of this report was to describe 4 cases of acute corneal transplant rejection occurring in association with coronavirus disease 2019 (COVID-19) mRNA vaccination. METHODS: Four patients with prior keratoplasty developed presumed immunologic rejection after the mRNA-1273 vaccination for coronavirus 2 (SARS-CoV-2). Case 1 had received Descemet membrane endothelial keratoplasty 6 months ago and presented with endothelial graft rejection 3 weeks after the first vaccine dose. Case 2 had undergone penetrating keratoplasty 3 years previously and presented with acute endothelial rejection 9 days after the second vaccine dose. Case 3 had prior Descemet stripping automated endothelial keratoplasty (DSAEK) and began experiencing symptoms of endothelial graft rejection 2 weeks after the second vaccine dose. Case 4 presented with endothelial rejection of the penetrating keratoplasty graft 2 weeks after the second vaccine dose. RESULTS: Frequent topical corticosteroids alone were initiated in all 4 cases. In case 1, the endothelial rejection line appeared fainter with improvement in visual acuity and corneal edema 5 weeks after diagnosis. Case 2 experienced complete resolution of corneal stromal edema and rejection line 6 weeks after diagnosis. Cases 3 and 4 have both experienced initial improvement with steroid treatment as well. CONCLUSIONS: These cases suggest acute corneal endothelial rejection may occur soon after either dose of the COVID-19 mRNA vaccine. Prompt initiation of aggressive topical steroid therapy may result in complete resolution of clinical signs and symptoms. Further studies are needed to elucidate the causal mechanism of corneal graft rejection after COVID-19 vaccination.

Acute Thyroiditis and Bilateral Optic Neuritis following SARS-CoV-2 Vaccination with CoronaVac: A Case Report.

PURPOSE: To describe a case of acute thyroiditis and bilateral optic neuritis associated with SARS-CoV-2 vaccination. METHODS: A single case report from a tertiary referral center. RESULTS: The patient described in the following case report developed acute thyroiditis and bilateral optic neuritis following SARS-CoV-2 vaccination. The patient underwent pulse therapy followed by oral tapering corticosteroid therapy with an improvement of the bilateral disc swelling and the visual field, and recovery of thyroid-stimulating hormone to the normal limits. CONCLUSION: Although the association between immunization and the onset of demyelinating manifestations of the central nervous system is well documented, this is the first reported case of bilateral optic neuritis and acute thyroiditis and subsequent to administration of vaccination against SARS-CoV-2.

Acute Uveitis following COVID-19 Vaccination.

PURPOSE: To describe a case of juvenile idiopathic arthritis (JIA)-associated anterior uveitis after receiving the Sinopharm COVID-19 vaccine. METHODS: A retrospective case report. RESULTS: An 18-year-old girl, with a history of antinuclear antibody positive oligoarticular JIA, presented with bilateral anterior uveitis 5 days after the second dose of the Sinopharm COVID-19 vaccine. Ocular examination revealed anterior uveitis with reduced visual acuity in both eyes. Anterior segment optical coherence tomography showed hyperreflective dots in the anterior chamber (AC) and fine endothelial granularities representing the circulating cells in the AC. Uveitis in both eyes resolved gradually after topical steroid treatment without recurrence. CONCLUSION: This report demonstrates a potential causal association of COVID-19 vaccine with anterior uveitis.

OUTCOMES IN PATIENTS RESUMING INTRAVITREAL ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY FOLLOWING TREATMENT DELAY DURING THE CORONAVIRUS-19 PANDEMIC.

PURPOSE: To evaluate the outcomes of delay in care secondary to the coronavirus pandemic in patients requiring intravitreal anti-vascular endothelial growth factor therapy. METHODS: A retrospective review was performed, and subjects were divided into two groups: 1) a study group of patients who experienced a treatment delay of ≥6 weeks from the intended follow-up during the coronavirus pandemic and resumed treatment with ≥2 anti-vascular endothelial growth factor injections over 6 months following treatment delay, and 2) a control group of patients who received regular care throughout the coronavirus pandemic. RESULTS: Totally, 234 subjects were analyzed. The mean treatment delay from the intended follow-up in the study group was 11.8 (±4.0) weeks. Visual acuity and central macular thickness worsened from baseline to 6 months after resuming anti-vascular endothelial growth factor therapy in the study group (P < 0.0001 and P = 0.001, respectively). Visual acuity and central macular thickness were better in the control group compared with the study group at the end of the 6-month study period (P < 0.0001 for both). CONCLUSION: Treatment delay in subjects undergoing anti-vascular endothelial growth factor therapy for retina disease during the coronavirus pandemic had worse visual and anatomical outcomes despite reinitiating treatment over 6 months compared with a control group, suggesting irreversibility and permanence of outcomes.

Ocular Surface Impairment After Coronavirus Disease 2019: A Cohort Study.

PURPOSE: This is a cohort study to evaluate the presence of objective signs and subjective symptoms of dry eye disease in postcoronavirus disease 2019 (COVID-19) patients compared with the control. METHODS: Prospective, observational, single-ctenter, cohort study. Sixty-four post-COVID-19 patients and 50 control were recruited. All participants underwent a complete ophthalmological examination including Ocular Surface Disease Index Questionnaire (OSDI), best-corrected visual acuity, slit-lamp biomicroscopy, fundus examination, Schirmer test type 1, tear break-up time test (tBUT), evaluation of conjunctival hyperemia, corneal staining, and tear film osmolarity test. RESULTS: The OSDI score was higher in the post-COVID-19 group in the quantitative and qualitative analysis (P < 0.001 and P =0.012, respectively). The mean tBUT in post-COVID-19 patients was 6.95 ± 4.07 seconds compared with a mean tBUT of 10.12 ± 3.90 seconds in the control group. The post-COVID-19 group showed a higher number of patients with a simultaneous impairment of the OSDI score and tBUT (P = 0.019). The Schirmer test results were strikingly significant both in the quantitative analysis and qualitative analysis (P <0.001 and P = 0.0014, respectively). Both quantitative analysis and qualitative analysis revealed a significant difference in tear osmolarity in the 2 groups. CONCLUSIONS: Comparing the ocular surface assessment of post-COVID-19 patients with heathy control, a statistically significant increase of dry eye disease has emerged both in subjective and objective evaluations. Our clinical results support the findings that suggested a susceptibility of the ocular surface to the virus, and it underlines the importance of the ocular surface assessment in post-COVID-19 patients for a correct diagnosis and therapy.

Low Visual Acuity Due to Acute Macular Neuroretinopathy Associated with COVID-19: A Case Report.

BACKGROUND Retinal sequelae have been reported in patients who have had COVID-19. This is a case report of acute macular neuroretinopathy (AMN), presenting with low visual acuity in the left eye, 14 days after the first symptoms of COVID-19 infection. CASE REPORT A 71-year-old woman presented for ophthalmological evaluation complaining of low visual acuity in the left eye, 14 days after the first symptoms of COVID-19 infection. COVID-19 was confirmed by a reverse-transcription polymerase chain reaction (RT-PCR) test. The left eye examination showed visual acuity of 0.5 logMAR, fundoscopy showed foveal pigment mobilization, fluorescein angiography revealed a hypofluorescent fovea surrounded by irregular hyperfluorescent defects, and spectral-domain optical coherence tomography showed central foveal thinning with disrupted interdigitation and ellipsoid zones. Given the clinical and imaging findings, the diagnosis of AMN was finalized. AMN usually resolves without specific treatment. CONCLUSIONS This case report shows that patients with COVID-19 can develop retinal involvement. AMN can be due to a viral infection, including COVID-19, and usually resolves without specific treatment. In the present case, there was no improvement in the patient's clinical condition in a 2-month follow-up to date.

Characteristics of endothelial corneal transplant rejection following immunisation with SARS-CoV-2 messenger RNA vaccine.

AIM: We report two cases of endothelial corneal allograft rejection following immunisation with SARS-CoV-2 messenger RNA (mRNA) vaccine BNT162b2 and describe the implications for management of transplant recipients postvaccination for COVID-19. METHODS: A 66-year-old woman with Fuchs endothelial corneal dystrophy (FECD) and a unilateral Descemet's membrane endothelial keratoplasty (DMEK) transplant received COVID-19 mRNA vaccine BNT162b2 14 days post-transplant. Seven days later, she presented with symptoms and signs of endothelial graft rejection. An 83-year-old woman with bilateral DMEK transplants for FECD 3 and 6 years earlier developed simultaneous acute endothelial rejection in both eyes, 3 weeks post second dose of COVID-19 mRNA vaccine BNT162b2. Rejection in both cases was treated successfully with topical corticosteroids. CONCLUSIONS: We believe this is the first report of temporal association between corneal transplant rejection following immunisation against COVID-19 and the first report of DMEK rejection following any immunisation. We hypothesise that the allogeneic response may have been initiated by the host antibody response following vaccination. Clinicians and patients should be aware of the potential of corneal graft rejection associated with vaccine administration and may wish to consider vaccination in advance of planned non-urgent keratoplasties. Patients should be counselled on the symptoms and signs that require urgent review to allow early treatment of any confirmed rejection episode.

Post COVID-19 opportunistic candida retinitis: A case report.

A 42-year-old male patient presented with profound impairment of vision in both eyes, just as he was recovering from COVID-19. A known diabetic and hypertensive, he suffered from COVID-19 pneumonia further complicated by ARDS, septicaemia and acute kidney injury. His vision on presentation was finger counting close to face bilaterally with multiple, yellowish lesions at the posterior pole. Based on the clinical findings and previous blood culture report, it was diagnosed as candida retinitis and treated with oral and intravitreal anti-fungals. The lesions were regressing at follow-up. This is a post COVID-19 presumed candida retinitis case report.

Optical coherence tomography angiography analysis of the retina in patients recovered from COVID-19: a case-control study.

OBJECTIVE: To quantify the density of the macular microvasculature and the area of the foveal avascular zone (FAZ) in patients recovered from coronavirus disease 2019 (COVID-19) using optical coherence tomography angiography (OCTA) analysis. METHODS: In a comparative cross-sectional, observational study, patients recovered from COVID-19 were included in this study. All included subjects exhibited a reverse transcription-polymerase chain reaction-confirmed diagnosis of COVID-19. Spectral domain macular OCTA was performed at least 2 weeks after recovery from systemic COVID-19. Vessel density (VD) of the superficial (SCP) and deep retinal capillary plexus (DCP) and the area of the FAZ were measured in COVID-19 recovered patients versus age-matched normal controls. RESULTS: Thirty-one recovered COVID-19 patients and 23 healthy normal controls were studied. Mean quality scan index was 7.64 ± 0.66 in the COVID cases and 8.34 ± 0.71 in the normal controls (p = 0.001). Mean SCP VD and DCP VD of the COVID cohort were significantly lower than the SCP VD and DCP VD of the control group in the foveal and parafoveal regions. FAZ area was greater in the COVID cohort, but this difference was not statistically significant. In addition, in the COVID cohort, VD of the SCP was lower in patients with a history of COVID-19 hospitalization versus those without such a history, but this did not reach statistical significance. CONCLUSIONS: Patients recovered from COVID-19 displayed alterations in the retinal microvasculature, including a significantly lower VD in the SCP and DCP. Patients with coronavirus infection may be at risk of retinal vascular complications.

Impact of the COVID-19 pandemic on characteristics of retinal detachments: the Canadian experience.

OBJECTIVE: To describe the impact of the coronavirus disease 2019 (COVID-19) pandemic on the characteristics of retinal detachments (RD) at a tertiary centre. DESIGN: Retrospective consecutive case series. PARTICIPANTS: One hundred and ninety eyes of 188 patients with primary, rhegmatogenous RD. METHODS: Patients with RD who presented over a 1-year period (September 14, 2019 to September 13, 2020). The relationship between demographic, anatomic, and visual acuity parameters were compared before and after onset of the pandemic using generalized estimating equations. MAIN OUTCOME MEASURES: Macular status and corrected distance visual acuity on presentation. RESULTS: One hundred and eighty-seven eyes, divided into 2 cohorts: pre-COVID (n = 100 September 14, 2019 to March 13, 2020) and post-COVID (n = 87, March 14, 2020 to September 13, 2020). Of the eyes, 63.2% (n = 87) presented with macular detachment in the post-COVID group compared with 45% (n = 100) in the pre-COVID group (odds ration [OR], 2.14; 95% confidence interval [CI],1.19-3.86; p = 0.011). As well, eyes in the pre-pandemic cohort had significantly fewer detached quadrants on initial examination (OR, 0.53; 95% CI, 0.30-0.93; p = 0.026). Patients in the post-COVID group had a significantly worse corrected distance visual acuity at baseline (mean difference [MD] = -0.35 logMAR, 95% CI, -0.60 to -0.09; p = 0.008), but not at 1 month or at final follow-up. No differences were seen between groups with respect to demographics, lens status, treatment, time to presentation, or chronicity. Pneumatic retinopexy was the most commonly performed procedure in both cohorts, with a 71.5% success rate. CONCLUSIONS: Closures after the COVID-19 pandemic affected the characteristics of RDs at presentation with respect to macular detachment, extent of RD, and presenting visual acuity. At final follow-up, final visual acuity and anatomic outcomes were similar between the 2 groups. These data are helpful for future patient education, triaging, and treatment decision making.

Acute Corneal Endothelial Graft Rejection With Coinciding COVID-19 Infection.

PURPOSE: To report a case of acute corneal endothelial graft rejection with the concurrent onset of coronavirus disease 2019 (COVID-19) symptoms. METHODS: Case report. RESULTS: A 31-year-old African American woman with a history of asthma, sleep apnea, obesity (body mass index of 40), and bilateral keratoconus was noted to have acute corneal endothelial graft rejection 3 months after uncomplicated penetrating keratoplasty of the left eye. The patient developed dysgeusia and subjective fever on the same day as ocular discomfort, and she was subsequently diagnosed with COVID-19 with only these 2 classic symptoms of the viral infection. CONCLUSIONS: Severe acute respiratory syndrome coronavirus 2 is known to cause conjunctivitis and has demonstrated transmissibility through ocular secretions. Acute immune and inflammatory dysregulations have been seen in cases of COVID-19 through various mechanisms. COVID-19 infection may potentially compromise ocular immune privilege contributing to acute corneal graft rejection.