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Year : 2022  |  Volume : 4  |  Issue : 1  |  Page : 26

Unilateral acute anterior sclero-uveitis preceding Corona virus disease (COVID-19)

Department of Uveitis and Ocular Immunology, Narayana Nethralaya, Bengaluru 560010, Karnataka, India

Date of Submission24-Feb-2022
Date of Acceptance17-Mar-2022
Date of Web Publication19-May-2022

Correspondence Address:
Srinivasan Sanjay
Department of Uveitis and Ocular Immunology, Narayana Nethralaya Super Speciality Hospital, Bengaluru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/pajo.pajo_14_22

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Coronavirus disease (COVID)-19 is associated with ophthalmic manifestations during and after recovery from the disease and may be sight-threatening. A 54-year-old Asian Indian female patient presented to us with redness, pain, and blurred vision in her right eye (RE) of 2-day duration. In RE, the best-corrected visual acuity was 20/25, and she was diagnosed with anterior sclero-uveitis. Three days later, she had mild breathlessness and loss of taste. Nasopharyngeal swab for reverse transcription–polymerase chain reaction-COVID-19 was positive, and investigations for uveitis were negative. The systemic evaluation was also within normal limits. A month later, she had no evidence of ocular inflammation. There was no other attributable cause to her ocular inflammation. Her COVID-19 immunoglobulin G antibody was positive, confirming the previous COVID-19 infection. The case emphasizes the importance for eye care professionals to remain vigilant and considers SARS-CoV-2 as the causative agent in patients presenting with anterior segment inflammation.

Keywords: Anterior uveitis, Corona virus disease-19, ocular manifestations, scleritis

How to cite this article:
Sanjay S, Kawali A, Agrawal S, Mahendradas P. Unilateral acute anterior sclero-uveitis preceding Corona virus disease (COVID-19). Pan Am J Ophthalmol 2022;4:26

How to cite this URL:
Sanjay S, Kawali A, Agrawal S, Mahendradas P. Unilateral acute anterior sclero-uveitis preceding Corona virus disease (COVID-19). Pan Am J Ophthalmol [serial online] 2022 [cited 2023 Sep 29];4:26. Available from: https://www.thepajo.org/text.asp?2022/4/1/26/345496

  Introduction Top

Coronavirus disease (COVID)-19 is associated with ophthalmic manifestations during and after recovery from the disease.[1],[2],[3],[4],[5],[6]

Conjunctival involvement, cotton wool spots and retinal hemorrhages, central retinal artery/vein occlusion, ophthalmic artery occlusion, panuveitis, papillophlebitis, retinitis with vascular occlusions, multifocal chorioretinitis, panuveitis, optic neuritis, central serous retinopathy, and Adie's syndrome are the ophthalmic manifestations associated with COVID-19 infection.[1],[2],[3],[4],[5],[6]

We herein report a case of unilateral anterior sclero-uveitis as a presenting manifestation in COVID-19.

  Case Report Top

A 54-year-old Asian Indian female with a previous history of thyroid surgery 35 years ago and occasional knee joint pain for which no treatment was sought presented to us with redness, severe pain, and blurred vision in her right eye (RE) of 2-day duration.

Best-corrected visual acuity (BCVA) was 20/25 in both eyes (BE). Slit-lamp examination in RE showed diffuse conjunctival and scleral congestion with chemosis, clear cornea, anterior chamber flare +1, and cells 1+. Phenylephrine 1% drops instillation did not blanch the congestion. Intraocular pressure was 17 mmHg in BE. Anterior vitreous was normal. Left eye was within normal limits. She was diagnosed to have anterior sclero-uveitis (RE).

Fundus evaluation was normal in both the eyes. Investigations done are elucidated in [Table 1]. Topical prednisolone acetate 1% 3 hourly and homatropine eye drops 2% were started in the RE and were advised to come for follow-up a week later, which she defaulted.
Table 1: Shows the investigations done at the time of presentation to our center

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Subsequently, 3 days later, she complained of mild breathlessness and acute loss of taste and consulted at a local hospital and was COVID-19 positive by reverse transcriptase–polymerase chain reaction.

She was treated at that hospital with multivitamin injection and syrup, pregabalin, and methylcobalamin combination daily and was advised home quarantine.

The patient used the topical eye drops for a week in the RE and stopped it as she felt better. A month later, she came back for an eye evaluation which showed a BCVA of 20/20 in BE. RE evaluation now was within normal limits.

  Discussion Top

Patients diagnosed with COVID-19 may have abnormal blood tests on admission, such as decreased or normal white blood cell count, decreased lymphocyte count, prolonged prothrombin time, increased D-dimer level, or increased aspartate aminotransferase, creatinine, creatine kinase, and lactate dehydrogenase, indicating coagulation abnormalities and organ dysfunction.[7] Our consulting rheumatologist ruled out the possibility of autoimmune/connective tissue diseases, including gout, after detailed clinical examination and investigations.

Post-COVID-19 reactivation of quiescent unilateral uveitis has also been reported many years later when the patient was in remission.[3]

There are also reports of post-COVID-19 hyper-inflammatory syndrome-associated with bilateral anterior uveitis and bilateral anterior uveitis with vitritis.[4],[5]

Isolated reports of episcleritis and anterior uveitis have been reported post-COVID-19 or in association with it.[8],[9] Our case is possibly the first to report isolated intraocular inflammation before COVID-19 diagnosis. The limitation of our case is that ocular inflammation could be idiopathic, and COVID-19 subsequently may have been coincidental.

Angiotensin-converting enzyme 2 (ACE2) receptors are present in all major organs; however, the density is particularly high in the lungs, heart, veins, and arteries. There is a high expression of ACE2 receptors within endothelial cells, making them vulnerable to Severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) binding and systemic endothelial dysfunction.[10] Endothelial alterations and endotheliitis tilt the vascular balance toward vasoconstriction, ischemia, tissue edema, and a procoagulant state.

COVID-19 can cause a pro-inflammatory cytokine response. The SARS-CoV-2 cytokine storm precipitates the onset of a systemic inflammatory response syndrome, resulting in the activation of the coagulation cascade and a hypercoagulable state. However, whether the coagulation cascade is directly activated by the virus or secondary to local or systemic inflammation is not clear.[11] Our patient had ocular inflammation followed by mild breathlessness and loss of taste 3 days later.

Our case demonstrates that acute anterior sclero-uveitis could precede the SARS-CoV-2 infection. The case emphasizes the importance for health-care professionals to remain vigilant and consider SARS-CoV-2 as a presumptive agent in patients presenting with anterior segment inflammation of the eye. This case could represent an early presentation of COVID-19.

  Conclusion Top

We report a patient who presented with acute uniocular inflammation, which preceded the loss of taste and subsequent diagnosis of COVID-19. Our patient did not have any other risk factors for ocular inflammation, and the rheumatologist had ruled out all autoimmune diseases; we presume that COVID-19 probably was preceded by ocular inflammation. All hitherto first episodes of ocular inflammation should have COVID-19 diagnosis as a possible cause.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initial will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Sanjay S, Gowda PB, Rao B, Mutalik D, Mahendradas P, Kawali A, et al. “Old wine in a new bottle” – Post COVID-19 infection, central serous chorioretinopathy and the steroids. J Ophthalmic Inflamm Infect 2021;11:14.  Back to cited text no. 1
Sanjay S, Srinivasan P, Jayadev C, Mahendradas P, Gupta A, Kawali A, et al. Post COVID-19 ophthalmic manifestations in an Asian Indian male. Ocul Immunol Inflamm 2021;29:656-61.  Back to cited text no. 2
Sanjay S, Mutalik D, Gowda S, Mahendradas P, Kawali A, Shetty R. Post coronavirus disease (COVID-19) reactivation of a quiescent unilateral anterior uveitis. SN Compr Clin Med 2021;3:1843-7.  Back to cited text no. 3
Sanjay S, R. Rao VK, Mutalik D, Mahendradas P, Kawali A, Shetty R. Post corona virus Disease-19 (COVID-19): Hyper inflammatory syndrome-associated bilateral anterior uveitis and multifocal serous retinopathy secondary to steroids. Indian J Rheumatol [serial online] 2021 [cited 2022 Apr 26];16:451-5.  Back to cited text no. 4
Sanjay S, Singh YP, Roy D, Mahendradas P, Kawali A, Shetty R. Recurrent bilateral idiopathic anterior uveitis with vitritis post Coronavirus Disease 2019 infection. Indian J Rheumatol [serial online] 2021 [cited 2022 Apr 26];16:460-3.  Back to cited text no. 5
Sanjay S, Agrawal S, Jayadev C, Kawali A, Gowda PB, Shetty R, Mahendradas P. Posterior segment manifestations and imaging features post−COVID-19. Med Hypothesis Discov Innov Ophthalmol. 2021 Fall; 10(3): 95-106. https://doi.org/10.51329/mehdiophthal1427.  Back to cited text no. 6
Tang D, Comish P, Kang R. The hallmarks of COVID-19 disease. PLoS Pathog 2020;16:e1008536.  Back to cited text no. 7
Méndez Mangana C, Barraquer Kargacin A, Barraquer RI. Episcleritis as an ocular manifestation in a patient with COVID-19. Acta Ophthalmol 2020;98:e1056-7.  Back to cited text no. 8
Benito-Pascual B, Gegúndez JA, Díaz-Valle D, Arriola-Villalobos P, Carreño E, Culebras E, et al. Panuveitis and optic neuritis as a possible initial presentation of the novel coronavirus disease 2019 (COVID-19). Ocul Immunol Inflamm 2020;28:922-5.  Back to cited text no. 9
To KF, Lo AW. Exploring the pathogenesis of Severe Acute Respiratory Syndrome (SARS): The tissue distribution of the coronavirus (SARS-CoV) and its putative receptor, Angiotensin-Converting Enzyme 2 (ACE2). J Pathol 2004;203:740-3.  Back to cited text no. 10
Becker RC. COVID-19 update: COVID-19-associated coagulopathy. J Thromb Thrombolysis 2020;50:54-67.  Back to cited text no. 11


  [Table 1]


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