Study of ocular manifestations of COVID-19 patients in a tertiary care hospital of Rural North Maharashtra

INTRODUCTION

COVID-19 is a novel disease that has caused a pandemic, unlike any other disease which we have experienced in modern medicine, not only because of the characteristics of the disease but also due to the rapidity of the spread of infection.

Some recent studies have shown that this new coronavirus strain can lead to conjunctival findings and can be detected in tears and conjunctival secretions.^[1] SARS-CoV-2 RNA has been detected through a reverse transcription–polymerase chain reaction (PCR) on conjunctival samples in 0–15% of infected patients.^[2,3]

The prevalence of eyelid, ocular surface, and anterior segment manifestations in different studies has varied from 0.81% to 34.5%.^[4,5] In COVID-19-recovered patients, a wide range of ocular symptoms is noted. Conjunctivitis is the most common manifestation and can develop at any stage of the disease. The exact pathogenetic mechanisms of the conjunctival infection are still unknown.^[6]

The present study aimed to study the profile of different ocular manifestations in recovered post-COVID-19 patients in tertiary care hospitals.

MATERIALS AND METHODS

The present study was a single-centre, prospective study conducted in the department of ophthalmology of a tertiary care hospital in rural North Maharashtra. The institutional ethics committee approved the study.

Our study is a prospective hospital-based case analysis study with a total of 104 cases. This was done for 14 months starting from April 2020 to June 2021.

RESULTS

In the present study, 104 patients were included. The majority of patients were from the young age group of 35–50 years and males (n = 69) outnumbered females (n = 35). Table 1 shows distribution of cases based on epidemiological profile and treatment received.

Diabetes mellitus (DM) (45.19%) was the most common comorbidity noted in study patients. The majority of patients presented with ocular symptoms in <1 month following COVID-19 infection (66.3%). For treatment of COVID-19 infection, the main medications received by study patients were injection remdesivir (66.3%) and injection dexamethasone (66.3%). Out of 104 cases under study, 46 (44.2%) patients required ventilator support during the treatment period.

In our study, we observed dryness of the eyes as the most common symptom in 31 cases (29.8%). Diagnosis of dry eye was confirmed with Schirmer’s test. Table 2 distribution of patients based on symptoms and signs observed.

In our study, the most common anterior segment pathology was observed viral conjunctivitis (47.11%), followed by orbital cellulitis with mucormycosis (20.19%). Table 3 shows cases distribution based on clinical diagnosis.

Orbital cellulitis is a severe and vision-threatening complication seen in COVID patients. An aggressive multidisciplinary approach is required for salvaging vision. Cellulitis with mucormycosis was observed in 21 patients (20.19%), majority of them were male (71.42%). Figure 1 shows case of orbital mucormycosis treated with surgical debridement. Injection amphotericin B (peribulbar, 3.5 mg on alternate days for 3 days) was used in 12 patients (57.14%) and oral posaconazole was used in 16 patients (76.19%). Surgical debridement was required in 12 patients (57.14%) and two patients required orbital exenteration. Mucormycosis cases were consulted by ENT and Dental specialists for combined management. Table 4 shows characteristics of patients presented with ocular mucormycosis. Partial 3^rd nerve palsy with intact extra ocular movements was seen 14 cases. (13.5%) Figure 2 shows case of Partial 3^rd nerve palsy.

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Figure 1:

Post COVID19 Orbital Cellulitis treated with surgical debridement.

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Figure 2:

Partial 3^rd nerve palsy in Left eye with intact extra ocular movements.

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DISCUSSION

Signs of COVID-19 conjunctivitis are similar to those of other viral infections, mostly bilateral conjunctival hyperemia, chemosis, the follicular reaction of the tarsal conjunctiva, epiphora, watery discharge, mild eyelid oedema, and enlarged preauricular and submaxillary lymph nodes.^[7] Direct effects due to the virus, immune-mediated tissue damage, activation of the coagulation cascade, and prothrombotic state induced by the viral infection and drugs used in the management are proposed mechanisms for conjunctival infection.^[6]

A review and meta-analysis of 16 studies was done by Aggarwa et al.^[8] included 2347 patients and a prevalence of 11.6% was observed.

Conjunctivitis is the most common ophthalmic manifestation documented in COVID-19 patients by Sindhuja et al.^[4] They reported that 8.66% of patients had conjunctivitis in cases with mild COVID-19 infection. In a study from Wuhan, China, from a total of 535 patients, about 20% had dry eye, 12% had blurred vision, 11% had foreign body sensation, 10% had epiphora and 9% had increased ocular secretion.^[9]

Two meta-analyses reported that conjunctivitis presented in 1.1% of COVID-19 patients^[10] and the pooled prevalence of conjunctivitis among COVID-19 patients was 5.5%.^[11]

Sen et al.^[6] studied 120 patients with ocular surface symptoms following COVID-19. The mean age was 45 years.

Tyagi et al.^[12] noted that from 1950 patients, only 7 (0.36%) had ophthalmic manifestations with conjunctival congestion being the most common sign (42.8%) observed. Similar findings were noted in the present study where viral conjunctivitis (47.11%) was the most commonly observed ocular manifestation.

Chen et al.^[5] found that 27 (5.04%) out of the 535 patients with COVID-19 had conjunctival congestion and the average duration of conjunctival congestion was 4.5 days.

Conjunctivitis (6.2%), xerophthalmia (4.5%), and keratitis (2.6%) were noted among them. Frequent hand-to-eye contact may be a risk factor for conjunctival congestion in patients with COVID-19.

There was a high frequency of ocular manifestations in hospitalized COVID patients and probably ocular manifestations could be a sign of more severe COVID disease. It could be a presenting sign of COVID and this should be kept in mind in all patients presenting with ocular manifestations, red eye in particular.^[13]

The use of steroids, monoclonal antibodies, and broad-spectrum antibiotics for the management of COVID-19 illness can increase the chances of new-onset fungal infection or exacerbate a pre-existing one.^[14]

The suggested mechanism for post-COVID orbital cellulitis and sinusitis is COVID-19-induced upper respiratory congestion which can compromise mucociliary clearance. Mucormycosis is an angioinvasive disease caused by fungi Mucorales such as Rhizopus, Mucor, Rhizomucor, Cunninghamella, and Absidia. The prevalence of mucormycosis in India is approximately 0.14 cases/1000 population, about 80 times the prevalence in developed countries.^[15]

Morbidity and mortality due to mucormycosis vary depending on the underlying medical condition, fungus type, and location. Mucormycosis is one of the serious, opportunistic infections noted in moderate-to-severe COVID-19. Compromised immune system with decreased CD4+ and CD8+ lymphocytes with associated comorbidities (e.g., DM and chronic obstructive pulmonary disease) and immunocompromised conditions (e.g., corticosteroid therapy, ventilation, and intensive care unit stay) were major factors for mucormycosis in COVID-19 patients.^[16]

Diagnosis of mucormycosis remains challenging. The clinical approach helps in raising suspicion and prompting the initiation of laboratory testing. Histopathology, direct examination, and culture remain essential tools. John et al.^[17] conducted a review of 41 cases of COVID-19-associated mucormycosis (CAMCR) and noted that CAMCR was typically seen in patients with DM (94%), especially the ones with poorly controlled DM (67%) and severe or critical COVID-19 (95%). DM is a significant risk factor for secondary infections.

Conservative debridement and transcutaneous retrobulbar injection of amphotericin B are being increasingly considered reasonable first-line options.^[18] Even with rapid diagnosis and initiation of treatment, prognosis is poor with mortality ranging from 21% to 80%.^[19,20]

Steroids and immunosuppressive medications must be used with caution during therapy, particularly in aged, immunocompromised, cancer, and diabetic patients with COVID.^[21] A high index of suspicion, early diagnosis with histopathological and microbiological evidence, appropriate management with antifungals and aggressive surgical debridement (functional endoscopic sinus surgery and orbital exenteration) can improve survival in patients of mucormycosis in COVID-19 patients.

CONCLUSION

COVID-19 can lead to various ocular symptoms even in the recovery period. It can lead to severe diseases such as mucormycosis. Early diagnosis with a high degree of suspicion and prompt treatment with a multidisciplinary approach is required for the prevention of visual disability.