Cogan's sign in a patient with suspected post-COVID-19 vaccine-associated myasthenia gravis.

The Cogan's sign is indicative of myasthenia gravis. This is the first report of neurological signs in a patient with post-COVID-19 vaccine-associated myasthenia gravis in Brazil. In this case, a previously healthy 68-year-old woman presented with proximal limb weakness, left ptosis, and diplopia 1 month after receiving her fourth dose of the COVID-19 vaccine. Neurological examination revealed the presence of Cogan's sign, and she recovered rapidly after treatment. To our knowledge, this is the first reported case of myasthenia gravis associated with the COVID-19 vaccine in Brazil.

Acute unilateral isolated ptosis as a complication of sinusitis in a post-COVID-19 patient.

A fit and well young man presented to our emergency department in the UK. On examination, he had an isolated left-sided ptosis; he had a 3-day history of frontal headache which was worse on head movement. He lacked any clinical signs of cranial, orbital, or preseptal infection, and his eye movements were normal. Ten days before presentation, he tested positive for SARS-CoV-2. Inflammatory markers were moderately raised, and CT of the head did not reveal any vascular abnormality or intracranial lesion. Imaging revealed opacification, predominantly in the left facial sinuses, keeping with sinusitis. He was discharged the same evening with oral antibiotics and made a full recovery over the next few days. He remained well at 6-month follow-up. The authors convey their findings to raise awareness of a rare complication of sinusitis and to demonstrate the utility of CT imaging for diagnosing sinusitis and ruling out severe pathology.

Telemedicine for Preoperative Evaluation of Upper Eyelid Malposition: Reliability of Diagnosis and Surgical Plan.

PURPOSE: Outpatient visits and surgeries for nonurgent indications in ophthalmology have intermittently been restricted during the COVID-19 pandemic. Telemedicine services have rapidly gained acceptance during this period, and could improve patient access for routine oculoplastic evaluations in the future. The objective of this study is to investigate interobserver and intraobserver reliability of eyelid and brow position assessment and surgical plan when comparing photography-based and face-to-face evaluation. METHODS: This was an observational study conducted at a single academic center. Thirty randomly selected patients who had completed an in-office evaluation for chief complaint of "drooping eyelids" between June 2019 and March 2020 were included. Virtual assessment of brow position, dermatochalasis, blepharoptosis, and margin-reflex distance 1 was performed by 2 oculoplastic surgeons based on external photographs, and a surgical plan was formulated. Fraction of agreement and Cohen's κ were determined to evaluate reliability of the virtual assessment compared to face-to-face examination. RESULTS: For 60 eyes from 30 study subjects, diagnostic reliability for observer A was near perfect for brow ptosis, substantial for blepharoptosis and moderate for dermatochalasis (κ = 0.86, 0.67, and 0.57, respectively); for observer B, reliability was moderate for brow and blepharoptosis and substantial for dermatochalasis (0.47, 0.59, and 0.79). Fraction of agreement for blepharoptosis was 94% in eyes where the eyelid margin was visible, and 66% in eyes where the eyelid margin was obscured by overhanging skin. Virtual margin-reflex distance 1 measurements were highly correlated with those obtained face to face (r = 0.77, p < 0.01). Fraction of agreement for surgical plan after virtual examination by observer A/B, respectively, was 100%/94% for brow lift, 90%/87% for blepharoptosis repair and 83%/83% for functional upper blepharoplasty. CONCLUSIONS: Virtual evaluation of upper eyelid and brow malposition can be performed with acceptable reliability. Co-existing dermatochalasis or brow ptosis may require special photographic technique or video examination to ensure an appropriate diagnosis. A photography-based preliminary surgical plan offers a viable alternative to face-to-face encounters.

Oculomotor nerve palsy in an asymptomatic child with COVID-19.

We report the case of a 2-year-old girl with acute-onset divergent strabismus and ptosis in the right eye. She had an exotropia of 45Δ for near, eyelid ptosis affecting the visual axis, adduction, limitations of up- and downgaze, and a discrete mydriasis in the right eye. Neurological conditions were ruled out. Serology was positive for SARS-CoV-2 antibodies. The patient was managed conservatively with ocular physiotherapy and close visual acuity monitoring. On follow-up examination at 1 month, there was marked improvement of the exotropia (25Δ for near), adduction, ptosis, and mydriasis.