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Table of Contents
Year : 2023  |  Volume : 5  |  Issue : 1  |  Page : 2

Anterior uveitis as the first manifestation of COVID-19 infection

1 Department of Ophthalmology and Visual Sciences, Universidade Federal De São Paulo – Escola Paulista de Medicina (Unifesp – EPM), São Paulo - SP; Médicos de Olhos SA, Curitiba - PR; Department of Ophthalmology, Hospital Federal dos Servidores do Estado do, Rio de Janeiro - RJ, Brazil
2 Médicos de Olhos SA, Curitiba - PR, Brazil
3 Department of Ophthalmology, Hospital Federal dos Servidores do Estado do, Rio de Janeiro - RJ, Brazil
4 Department of Ophthalmology and Visual Sciences, Universidade Federal De São Paulo – Escola Paulista de Medicina (Unifesp – EPM), São Paulo - SP, Brazil

Date of Submission31-Oct-2022
Date of Decision09-Nov-2022
Date of Acceptance10-Nov-2022
Date of Web Publication19-Feb-2023

Correspondence Address:
Aluisio Rosa Gameiro Filho
R. Botucatu, 822-Vila Clementino, São Paulo - SP
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/pajo.pajo_61_22

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The aim of this article was to report a well-documented case of anterior uveitis as the first manifestation of COVID-19. A 27-year-old male patient sought assistance at our emergency room complaining of bilateral painful conjuntival redness associated with photophobia for 3 weeks. These symptoms were followed by fever and chills, with a positive polymerase chain reaction for COVID-19. While his systemic symptoms improved, the ocular complaints remained. A complete panel for uveitis were performed, with negative results, except for COVID-19. The outbreak of COVID-19 in 2020 has several implications in our society. Previous reports described ocular manifestations of this condition. The ophthalmologists should be aware of the possibility of COVID-19 when facing a patient with red eye.

Keywords: SARS-CoV-2, uveitis, COVID-19, ocular manifestations

How to cite this article:
Gameiro Filho AR, Godoy R, Tura J, da Costa DS, de Souza CE, Nascimento Salomão HM. Anterior uveitis as the first manifestation of COVID-19 infection. Pan Am J Ophthalmol 2023;5:2

How to cite this URL:
Gameiro Filho AR, Godoy R, Tura J, da Costa DS, de Souza CE, Nascimento Salomão HM. Anterior uveitis as the first manifestation of COVID-19 infection. Pan Am J Ophthalmol [serial online] 2023 [cited 2023 May 29];5:2. Available from: https://www.thepajo.org/text.asp?2023/5/1/2/369997

  Introduction Top

In December 2019, a new virus has been reported in Wuhan, a province of China. Known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), this virus can cause a disease called COVID-19, which mostly affects the respiratory tract, but can also have gastrointestinal, neurological, cutaneous, and ocular symptoms. The most frequent ocular manifestation is conjunctivitis; however, several other ocular findings were already published. We aimed to report a case of COVID-19 in which the initial manifestation was anterior uveitis in a 27-years-old male patient.

  Case Report Top

A healthy 27-year-old male patient sought assistance at ophthalmology emergency room complaining of bilateral painful conjunctival redness, without secretions, associated with photophobia, and visual loss that had started 3 weeks before. At that time, he went to a general emergency hospital, in which he was evaluated by a generalist, and only a lubricant agent was prescribed. Three days later, he came back to the general emergency with the same complaints, now associated with headache, myalgia, generalized arthralgia, fever, and chills. A polymerase chain reaction (PCR) for COVID-19 was performed, with a positive result. Social isolation for 15 days was oriented, with complete resolution of the systemic symptoms, and a partial improvement of conjunctival redness; however, the ocular pain and the blurred vision remained unchanged. He denied any systemic diseases, allergies, or use of any sort of medications. He also denied having similar ocular symptoms before. His family and personal ocular history were also negative.

On ophthalmological evaluation, his best-corrected visual acuity (BCVA) was 20/30 in both the eyes. Biomicroscopy revealed anterior chamber cells (0.5+) and posterior synechiae on the right eye (OR). On the left eye (OS), it revealed anterior chamber cells (2+), epiphora, ciliary injection, conjunctival redness, nongranulomatous keratin precipitates, and posterior synechiae [Figure 1]. Intraocular pressure was 14 in both the eyes, and fundoscopy was unremarkable. Topical steroids and tropicamide 1% were initiated at this moment. A complete serological panel for infectious and noninfectious uveitis was requested, including arboviruses, dengue fever, chikungunya, and yellow fever, all with negative results, except for a COVID-19 IgG+.
Figure 1: Biomicroscopy showing anterior chamber cells, ciliar injection, conjunctival redness, and non-granulomatous keratin precipitates (black arrow)

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Multimodal imaging, with fluorescein angiography and fundus autofluorescence, was also normal. The patient was referred to a rheumatologist for a complete evaluation, with normal results. After 3 weeks of treatment, the patient referred a complete resolution of the symptoms [Figure 2] and BCVA returned to 20/20. The patient had been followed for 11 months, without recurrences.
Figure 2: Ectoscopy of the patient at the first evaluation (upper image) and after treatment (bottom image)

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  Discussion Top

The first reported case of the new coronavirus was in Wuhan, China, in December 2019, and rapidly spread globally, claiming lives of millions. On January 20, 2020, it was declared a public health emergency on international concern, and 2 months later, it was labeled as a pandemic by the World Health Organization. The causative pathogen of this disease is called SARS-CoV-2, which is a novel enveloped, positive single-stranded RNA, and belongs to the genus Betacoronavirus, a member of the Coronaviridae family. It is highly transmissible and spreads mainly by droplets released during sneezing, coughing, talking, or breathing. Indirect transmission can also occur through surface contamination.[1],[2] Direct contact with mucous membranes, including conjunctiva, and through tears is also a suspected route of transmission.[3],[4]

The most common findings are related to respiratory tract. In general, Betacoronavirus are responsible for lower respiratory affections, such as atypical pneumonia, while most of coronaviruses affect the upper respiratory tract; this is due to the difference infection sites: SARS-Cov and SARS-Cov-2 are capable of using the angiotensin converting enzyme 2 (ACE 2)-present in the lower respiratory tract-to infect human cells.[5] This expression is not limited to the lower respiratory tract, it is also found in proximal tubule of kidney and bladder urothelium, in myocardial cells, esophagus, ileum and in the eye, more specifically in the conjunctiva, limbus, cornea, retina, and aqueous humor, which explains the reason why coronavirus can affect these tissues.[6],[7]

Since the outbreak of this pandemic, several reports of ocular manifestations of COVID-19 have been published. Usually, they occur 2 weeks after the initial symptoms;[1] however, they can be the presenting finding of a newly diagnosed COVID-19 patient, such as in our case. A systematic review estimates that ocular manifestations were the first symptoms in 2.26% of patients with COVID-19.[8] The overall prevalence of ocular manifestations in these patients is around 11%,[8],[9] and while some reports associate ocular manifestations with more severe respiratory symptoms,[10] other studies which compared the percentage of ocular symptoms between patients in intensive care unit (ICU), semi-ICU and outpatients could not show any difference in the percentage of ocular symptoms among these groups.[11]

Nasiri et al.[9] published a systematic review of 38 studies about ocular manifestations in COVID-19 patients, encompassing roughly 8200 patients, and showed that the most frequent ocular manifestations were dry eye or foreign body sensation (16%), followed by redness (13.3%), tearing (12.8%), itching (12.6%), eye pain (9.6%), and discharge (8.8%). Regarding the most prevalent ocular diseases, the most frequent was conjunctivitis (88.8%), keratitis (2.2%), episcleritis (2.2%), keratoconjunctivitis (2.2%), and posterior ischemic neuropathy (1.1%).

The most frequent ocular finding in patients with COVID-19 is follicular conjunctivitis, with a prevalence that ranges from 0.8% to 32% of patients with COVID-19 presenting with conjunctivitis.[1],[12] On eyelids, cases of acute tarsadenitis and multiple cases of chalazion have been reported; however, it is hypothesized that they can occur due to occupational conditions, such as using masks or eye goggles that due to the virus itself.[13] Although rarer, cases of episcleritis have already been reported by Ceran and Ozates.[14] Of the 93 patients evaluated, 2 (2.2%) had this ocular manifestation, which was associated to a higher D-dimer level.

Regarding neuro-ophthalmologic complications, Miller–Fisher syndrome, optic neuritis, acute disseminated encephalomyelitis, and cranial nerve palsies have been reported.[1],[15] As for retinal and choroidal findings, Marinho et al.[16] reported hyperreflective lesions at the level of ganglion cell and inner plexiform layers, as well as microhemorrhages and cotton wall spots. The same group also showed presumed SARS-CoV-2 viral particles in human retina.[17] Acute macular neuroretinopathy, paracentral acute middle maculopathy, Purtscher-like retinopathy, and thromboembolic events, such as central artery occlusion or vein occlusion, have also been described.[18],[19],[20]

Only a few cases of uveitis have been reported in association with COVID-19 until the present days. Bettach reported a case of a 54-years-old patient, who had bilateral anterior conjunctivitis as a part of multisystem inflammatory syndrome.[21] Mazzotta and Giancipoli[22] described a case of a 30-year-old female patient presenting with anterior conjunctivitis associated with follicular conjunctivitis. Iriqat et al.[23] reported 3 cases: a 19-year-old male patient with anterior uveitis 5 weeks postpositive PCR for COVID-19; a 29-year-old male patient with intermediate and posterior uveitis; and a 62 year-old patient with glaucoma that developed anterior uveitis that started after the systemic symptoms of COVID. Other cases of reactivation of uveitis after COVID infection[24] or uveitis after COVID-19 vaccination have also been reported.[25] More recently, cases of serpiginous and ampiginous choroiditis following COVID-19 were published.[26],[27] As far as we know, our case is the first time that an isolated anterior conjunctivitis presented as the first manifestation of COVID-19 infection.

  Conclusion Top

We reported a case of a young male patient with anterior uveitis as the first manifestation of COVID. Fortunately, he recovered from his systemic and ophthalmological findings, without need of hospitalization. COVID-19 has been associated with multiple ocular findings. The presence of ACE2 in ocular tissues could explain a possible ocular tropism, as do other respiratory viruses. We present this case of anterior uveitis as the first manifestation of COVID-19 infection to emphasize the importance for the health-care providers to be aware of the possible inflammatory ocular manifestation during and after a COVID-19 infection. The ophthalmologist should be aware of this possibility, especially when facing a patient with red eye and systemic COVID-19 symptoms.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Seah IY, Anderson DE, Kang AE, Wang L, Rao P, Young BE, et al. Assessing viral shedding and infectivity of tears in coronavirus disease 2019 (COVID-19) Patients. Ophthalmology 2020;127:977-9.  Back to cited text no. 3
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  [Figure 1], [Figure 2]


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