key: cord-0811742-mkpizk7u
authors: Sainath, Dipika; Paul, Anujeet; Krishnagopal, Srikanth; Kumar, Ashok
title: Acute bilateral retrobulbar optic neuritis - An atypical sequela of COVID-19
date: 2021-11-26
journal: Indian J Ophthalmol
DOI: 10.4103/ijo.ijo_2155_21
sha: 6519b4daf80f4d600782358b61029100602f5567
doc_id: 811742
cord_uid: mkpizk7u

Coronavirus disease 19 (COVID-19) and its ophthalmic manifestations have been variably portrayed. We report a case of a 56-year-old female presenting with sudden-onset vision loss associated with painful extraocular muscle movements in both eyes following COVID-19. Visual acuity was counting fingers close to face. Color perception tested was inaccurate. Ocular examination revealed sluggishly reacting pupils and an otherwise unremarkable fundus picture in both eyes, giving us an impression of bilateral retrobulbar neuritis. Magnetic resonance imaging of the brain and orbit were unremarkable, while blood investigations revealed nothing suggestive. The patient dramatically improved with steroid therapy with full visual recovery and a color vision defect. This presentation of bilateral retrobulbar neuritis as a sequela of COVID-19 is presented for its rarity.

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. Chest X-ray and Mantoux skin test were negative. Blood inflammatory markers, including C-reactive protein, procalcitonin, D-dimer, ferritin, and lactate dehydrogenase, were within reference limits, and blood analysis was negative for infectious pathology. She was screened for autoimmune optic neuritis, but the results from all investigations were unremarkable, including screens for anti-myelin oligodendrocyte glycoprotein antibodies, aquaporin-4 antibodies, and myelin-associated glycoprotein antibodies. Her basic metabolic and immunologic work-ups as well as her cerebrospinal fluid studies revealed nothing remarkable [ Fig. 2 ].

Magnetic resonance imaging (MRI) of the brain and orbit revealed swelling of the right retrobulbar intraorbital segment of the optic nerve with a high T2 signal [ Fig. 3 ]. Brain parenchyma was normal. A diagnosis of bilateral retrobulbar optic neuritis was made. She was started on intravenous pulsed methylprednisolone 250 mg every 6 hourly/day × 3 days, followed with an oral dose of methylprednisolone 1 mg/kg/weight once daily × 11 days as per Optic Neuritis Treatment Trial (ONTT) under glycemic check. [5] The patient improved dramatically within 1 week, with Snellen visual acuity 6/9 in both eyes and a defective color vision. Visual fields (30-2) on recovery showed a paracentral scotoma in both eyes. Optical coherence tomography (OCT) showed healthy retinal nerve fiber layers (RNFL) with an average thickness of 111 µm and 114 µm, respectively [ Fig. 4 ].

The coronavirus disease, though primarily a disease of the respiratory system with life-threatening complications, has now been well reported to have ophthalmic associations and complications. [1, 3] Though neuro-ophthalmic manifestations in concurrence with COVID-19 have been sparsely reported, they cannot be overlooked. [1] Ocular transmission is postulated to use the angiotensin-converting enzyme-2 receptor (ACE2) expressed in the central nervous system, including retinal vessels to enter the cell. [2, 6, 7] Another speculation includes direct neuronal entry by the virus, leading to endothelial cell dysfunction causing ischemia and coagulopathy. [6] Neuronal involvement also occurs due to viremia traversing the blood-brain barrier or via infected leukocytes. [2] Optic neuritis, an inflammation of the optic nerve head, presents as papillitis, retrobulbar neuritis, or neuroretinitis. [5, 8] It is primarily a clinical diagnosis based on history and examination findings. Funduscopic features aid in differentiating typical from atypical cases. [4, 8] In adults, optic neuritis is usually unilateral and commonly linked to multiple sclerosis (MS). [3, 5, 8] It has been speculated that the SARS-CoV-2 virus may cause relative hypoxia leading to neuroinvasion of the virus progressing to optic neuropathy. [2, 6] Laterality of optic neuropathy remains significant as the occurrence is usually unilateral. Bilateral acute optic neuritis is a rare manifestation, particularly in the absence of systemic inflammatory or autoimmune disorders. [2, 5, 8] A study reported increased ganglion cell layer thickness (GCL) in multiple quadrants in individuals who had recovered from COVID-19; however, optical coherence tomography performed in our patient showed healthy ganglion cell complex. [6] Though extensive differential diagnostic testing is warranted to treat the underlying cause, in our patient, blood and neuroimaging revealed nothing noteworthy. [5] Studies have reported the aggravation of MS as well as recurrence of optic neuritis in the setting of COVID-19. [1, 8, 9] Sardar et al. [10] reported a case of optic neuritis and idiopathic intracranial hypertension in coexistence with COVID-19. A meta-analysis on post-COVID-19 optic neuritis revealed a female preponderance, with preference of left eye and no significant correlation between recovery and treatment. [11] However, there have been no reported cases to the best of our knowledge that describe bilateral retrobulbar neuritis post COVID-19 without any triggering factor and with prompt recovery on initiation of steroids. Thus, we report this case for its rarity.

Acute bilateral sudden loss of vision as a post-COVID-19 sequela should be promptly managed and extensively evaluated. Ruling out an infective, inflammatory, or autoimmune history is prudent to the management of such a case and a diagnosis of bilateral retrobulbar neuritis should be kept in mind while evaluating such a case.

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Nil.

There are no conflicts of interest.

Neuro-ophthalmic manifestations of coronavirus disease 19

Optic neuritis following SARS-CoV-2 infection

Ocular manifestations of COVID-19 (SARS-CoV-2): A critical review of current literature

Clinical profile of simultaneous bilateral optic neuritis in adults

Management of optic neuritis

Optic nerve analysis in COVID-19 patients

COVID-19-Induced acute bilateral optic neuritis

Atypical optic neuritis: An overview

Myelin oligodendrocyte glycoprotein antibodyassociated optic neuritis in a COVID-19 patient: A case report

The diagnostic dilemma of bilateral optic neuritis and idiopathic intracranial hypertension coexistence in a patient with recent COVID-19 infection

Optic neuritis post-COVID-19 infection. A case report with meta-analysis

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

We present the case of a 23-year-old young man with left-eye abducens nerve palsy following the COVID-19 vaccination. Given the temporal relationship between vaccination and the onset of symptoms, the lack of systemic history, and unremarkable magnetic resonance imaging, the patient's abducens nerve palsy was related to his vaccination. The ophthalmologist should be aware of this neurotropic sequela of COVID-19 vaccination in young adults.

Sixth nerve palsy in the young adult population is rare and presents with acute esotropia and limited abduction on the affected side, commonly due to neoplasm, trauma, elevated intracranial pressure, inflammation, and infections. [1, 2] According to reports of the US Vaccine Adverse Event Reporting System, the most common motor palsy following vaccinations in the pediatric age group are third, fourth, and abducens nerve. [3] [4] [5] In the pediatric age group, the onset of nerve palsies secondary to immunization ranges from days to months, resolves by 6 months, and has a predilection to affect the left eye. [5, 6] We present the case of a young man with unilateral abducens nerve palsy post Covishield vaccination.

A healthy 23 year male presented to the clinic for suddenonset diplopia along with severe headache since 1 week. He denied any history of trauma or any recent illness. He had received his first dose of COVID-19 (Covishield, Serum Institute of India) vaccination 1 week prior. BCVAs were 20/20 OD, OS. Cover test revealed a 40 PD left esotropia with limited abduction of the left eye [ Fig. 1a ]. Dilated fundus examination was unremarkable. The patient had neuroimaging with MRI and MRA, which revealed no abnormality. Reverse transcription-polymerase chain reaction (RT-PCR) test was negative. All blood investigations, including complete blood count, fasting blood sugar, and antinuclear antibodies (ANA), were normal.He had history of two similar episodes in the past. During both episodes, his MRI and blood investigations were unremarkable. He had the first episode of LE sixth nerve palsy following fever 5 years back for which LE Botox injection to medial rectus was given with complete resolution after 2 months. He had a similar episode in LE after 2 years of the initial episode following chickenpox with complete resolution in 3 months.In his current visit, he had LE sixth nerve palsy following the COVID-19 vaccination. Subsequent follow-up examinations showed abduction improved to near normal [ Fig. 1b ].

Cranial nerve palsies have been reported after multiple vaccines. The most common vaccines include the hepatitis