COVID-19 infection linked to neurologic, neuro-ophthalmic complications
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A literature review documented manifestations of central and peripheral nervous system disease, including along afferent and efferent visual pathways, related to COVID-19 infection, according to data in the Journal of Neuro-Ophthalmology.
“Acute and chronic neurologic and neuro-ophthalmic symptoms continue to be described and characterized as our understanding of infection and postinfectious complications evolve,” Marcela Marsiglia, MD, PhD, a diagnostic radiologist at Massachusetts General Hospital and Harvard Medical School in Boston, and colleagues wrote. “Ocular manifestations were described early in the pandemic, and detailed descriptions of neuro-ophthalmic manifestations have since been reported.”
Seeking to review and summarize COVID-19-related neurologic and neuro-ophthalmic complications, Marsiglia and colleagues searched PubMed and Google Scholar for literature on relevant imaging manifestations of neurologic and neuro-ophthalmologic disease, including those that affect the afferent and efferent visual pathways.
From the afferent perspective, the authors found reports of fundus nodules on MRI, papilledema, optic neuritis, acute disseminated encephalomyelitis, vascular injury with thromboembolism and infarct, leukoencephalopathy, hemorrhage, gray matter hypoxia, infectious meningitis and encephalitis, acute necrotizing hemorrhagic encephalopathy and posterior reversible encephalopathy syndrome.
Complications involving the efferent visual system included orbital abnormalities, cranial neuropathy, Guillain-Barré and Miller Fisher syndromes, nystagmus and other eye movement abnormalities related to rhombencephalitis.
According to the authors, thromboembolic infarcts were the most recognized severe neurologic complication of COVID-19 infection early in the pandemic.
“Familiarity with the wide variety of neurologic, ophthalmic and neuroradiologic presentations can promote prompt and appropriate treatment and contribute to building a framework to understand the underlying mechanisms of disease,” Marsiglia and colleagues concluded.
Perspective
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Debora Lee Chen, OD, MPH, FAAO
Fever, chills, difficulty breathing, new loss of taste or smell, fatigue, cough – these systemic signs have been well-associated with the novel coronavirus since its entrance in late 2019. We are now starting to identify the many ways COVID affects the eyes and visual system.
This narrative review reminds us to consider careful funduscopy, eye movement and extraocular movement evaluation, and ancillary neurologic or neuro-ophthalmic testing when examining a patient with a history of COVID. From a differential diagnosis standpoint, we can also add COVID to our list of systemic causes for diplopia, bilateral vision loss, papilledema, optic neuritis, nystagmus and other eye movement abnormalities. Regarding further workup, neuroimaging may be warranted for radiological visualization of vascular injury, infarction and encephalopathy, although we need more specific guidance on this. There may also be visual cortex involvement, either from the disease itself or due to hypoxia. This may result in visual processing deficits and likewise require further workup or referral. In all, nearly 3 years later, we are seeing just the tip of the iceberg regarding acute and longer-lasting neurologic and neuro-ophthalmic manifestations of the disease.
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