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• A supporting case for this profound presentation
  Evelyn Qian, Stephen Burgess
  Published on: 2 December 2021

• Published on: 2 December 2021

  A supporting case for this profound presentation

  • Evelyn Qian, Foundation Doctor NHS Lothian
  • Other Contributors:
    • Stephen Burgess, Consultant Ophthalmologist

  Jiang presents a very interesting and unique case of bilateral corneal decompensation in a patient with COVID pneumonitis. We would like to offer a similar case to support their hypothesis of viral endotheliitis. These cases demonstrate an ocular manifestation of COVID-19 infection which was previously unknown. This manifestation is important to be aware of as the subsequent visual impairment may be profound, though likely amenable to treatment.

  Jiang pointed out the unclear onset for their case and possible delayed presentation from 34 days of ventilation. While we cannot assume the onset time of Jiang’s patient, our patient provides an interesting comparison. Our case describes a male patient who developed significant and painless overnight vision loss. He had gone to bed with only cough as a symptom of COVID infection and awoke to find himself only able to perceive light and gross motion. This patient presented to our local accident and emergency department with this sudden and profound bilateral loss of vision. He required admission due to his inability to self-care.

  On examination the patient was found to have significant bilateral corneal oedema. Both eyes were white with no evidence of local infection, inflammation, or ocular surface trauma. There was no epithelial uptake with fluorescein in either eye. Intraocular pressure was within normal limits and symmetrical. No corneal dystrophy could be seen with biomicroscopy. The patient was started on topi...

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  Jiang presents a very interesting and unique case of bilateral corneal decompensation in a patient with COVID pneumonitis. We would like to offer a similar case to support their hypothesis of viral endotheliitis. These cases demonstrate an ocular manifestation of COVID-19 infection which was previously unknown. This manifestation is important to be aware of as the subsequent visual impairment may be profound, though likely amenable to treatment.

  Jiang pointed out the unclear onset for their case and possible delayed presentation from 34 days of ventilation. While we cannot assume the onset time of Jiang’s patient, our patient provides an interesting comparison. Our case describes a male patient who developed significant and painless overnight vision loss. He had gone to bed with only cough as a symptom of COVID infection and awoke to find himself only able to perceive light and gross motion. This patient presented to our local accident and emergency department with this sudden and profound bilateral loss of vision. He required admission due to his inability to self-care.

  On examination the patient was found to have significant bilateral corneal oedema. Both eyes were white with no evidence of local infection, inflammation, or ocular surface trauma. There was no epithelial uptake with fluorescein in either eye. Intraocular pressure was within normal limits and symmetrical. No corneal dystrophy could be seen with biomicroscopy. The patient was started on topical Predforte drops which were administered 2 hourly to both eye. He was also given topical lubrication in the form of celluvisc 0.5% four times a day to both eyes. Notably, viral eye swabs taken from the conjunctival sac were positive for COVID and negative for HSV and VZV. Viral eye swabs as a diagnostic tool for aetiology of ocular pathology is of unknown specificity, though has been widely suggested in the literature (1).

  This gentleman was rather comorbid with, notably, diabetes, hypertension, obesity and stable sarcoidosis. He had no ophthalmic history or family history of note. Though he suffered from polypharmacy, he was not on any medication known to cause corneal decompensation and no significant medication changes had been made within 12 months of his admission. His chest x-ray on admission showed only air space shadowing consistent with COVID pneumonitis. Therefore, there were no other obvious causes of corneal decompensation (2).

  Systemically our gentleman was also found at admission to have an acute kidney injury and hypoglycaemia. This was thought to be secondary to his inability to feed himself with his acutely deteriorated eyesight. Hypoglycaemia was treated by the paramedics, but his kidney injury worsened and ultimately, sadly, resulted in death at 72 hours after admission. The patient was reviewed daily and interestingly, as his kidney function continued to deteriorate his corneal oedema began to improve. His vision improved to counting fingers in each eye. As noted by Jiang, this systemic upset is unlikely to be the cause of corneal decompensation which is usually due to a more local insult. Hence the most likely cause and perhaps supported by the positive swab is viral endotheliitis secondary to COVID-19 infection.

  Supporting Jiang’s case, we, similarly have a case of profound bilateral corneal decompensation for which all differentials for cause had been ruled out and leaving viral endotheliitis secondary to COVID infection the most likely cause. In comparison to Jiang’s case, our gentleman shows that acute deterioration is possible, and importantly, this manifestation of disease may occur throughout the range of the severity of COVID pneumonitis. Reassuringly, both patients have shown good initial responses to topical treatment with steroids. The literature continues to grow with profound manifestations of COVID pneumonitis, it remains of utmost importance to be aware of these presentations especially when they may present across the range of COVID severity.

  (A note to the editor: we have submitted this letter with the purpose outlined above. If consent from this patient’s relatives is required, please let us know. Many thanks for reading this letter.)

  References:

  1. Kaur P, Sehgal G, Shailpreet, Singh K, Singh B. Evaluation and comparison of conjunctival swab polymerase chain reaction results in SARS-CoV-2 patients with and without ocular manifestations. 2021.

  2. Moshirfar M, Murri M, Shah T, Skanchy D, Tuckfield J, Ronquillo Y et al. A Review of Corneal Endotheliitis and Endotheliopathy: Differential Diagnosis, Evaluation, and Treatment. 2021.

  Summary:

  A supporting case from Dr Evelyn Qian, Lothian describes similar ocular manifestation and positive conjunctival swab PCR relating to severe COVID pneumonitis, in support of our hypothesis of SARS-CoV-2 viral endotheliitis which was previously unknown.

  Qian describes a case of acute bilateral corneal oedema in the presence of severe COVID-19. Conjunctival swabs were positive for SARS-CoV-2 by rRT-PCR assay, and negative for HSV and VZV. His ocular condition was treated with topical steroid drops which demonstrated clinical improvement before he passed away from acute kidney injury at 72 hours after admission.

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  Conflict of Interest:
  None declared.

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