British Journal of Ophthalmology

Ocular manifestations of a hospitalised patient with confirmed 2019 novel coronavirus disease

Lu Chen, Meizhou Liu, Zheng Zhang, et all

Purpose To report the ocular characteristics and the presence of viral RNA of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in conjunctival swab specimens in a patient with confirmed 2019 novel coronavirus disease (COVID-19).

Participant and methods A 30-year-old man with confirmed COVID-19 and bilateral acute conjunctivitis which occurred 13 days after illness onset. Based on detailed ophthalmic examination, reverse transcription PCR (RT-PCR) was performed to detect SARS-CoV-2 virus in conjunctival swabs. The ocular characteristics, presence of viral RNA and viral dynamics of SARS-CoV-2 in the conjunctival specimens were evaluated.

Results Slit lamp examination showed bilateral acute follicular conjunctivitis. RT-PCR assay demonstrated the presence of viral RNA in conjunctival specimen 13 days after onset (cycle threshold value: 31). The conjunctival swab specimens remained positive for SARS-CoV-2 on 14 and 17 days after onset. On day 19, RT-PCR result was negative for SARS-CoV-2.

Conclusion SARS-CoV-2 is capable of causing ocular complications such as viral conjunctivitis in the middle phase of illness. Precautionary measures are recommended when examining infected patients throughout the clinical course of the infection. However, conjunctival sampling might not be useful for early diagnosis because the virus may not appear initially in the conjunctiva.

Clinical and in vivo confocal microscopic features of neuropathic corneal pain

Andrew R Ross, Mouhamed Ali Al-Aqaba, Amna Almaazmi1. Et all

Aims To describe clinical and in vivo confocal microscopy (IVCM) features of neuropathic corneal pain (NCP) without clinically visible signs.

Methods Prospective, observational study of 27 eyes of 14 patients who had continuous severe ocular pain for one or more years, with minimal or no ocular surface signs and were non-responsive to topical lubricants, steroids and/or ciclosporin. All patients were evaluated using Ocular Surface Disease Index, Oxford grading scale, Schirmer test 1, Cochet Bonnet esthesiometry and response to topical anaesthesia. Central and paracentral regions of the cornea of patients and seven healthy controls were studied by IVCM. Corneal epithelial thickness and sub-basal nerve density were measured in patients and controls.

Results Four patients responded to topical anaesthesia (responsive group (RG)), indicating peripheral NCP while 10 patients did not show any improvement (non-responsive group (NRG)), indicating central NCP. Schirmer-1 test was within normal limits in the RG but significantly greater in the NRG (p<0.001). None of the other clinical parameters nor corneal epithelial thickness were statistically significantly different. The sub-basal nerve density was significantly reduced (p<0.008) in patients compared with controls. Stroma of all patients demonstrated activated keratocytes and spindle, lateral and stump microneuromas. There was a statistically significant greater number of microneuromas (p<0.0001) and activated keratocytes in RG compared with NRG.

Conclusion NCP without visible clinical signs does not represent typical dry eye disease. Distinct signs demonstrated on IVCM suggest that peripheral NCP, which responds to topical anaesthesia, and central NCP, which does not, are separate entities.

Dupilumab-induced ocular surface disease (DIOSD) in patients with atopic dermatitis: clinical presentation, risk factors for development and outcomes of treatment with tacrolimus ointment

Yoav Nahum, Michael Mimouni, Eitan Livny, et all

Aim To identify risk factors for the development of dupilumab-induced ocular surface disease (DIOSD) in adult patients with atopic dermatitis (AD) and describe outcomes of treatment.

Methods A retrospective institutional cohort study performed at the Rabin Medical Center, Petach Tikva, Israel. Adult patients with AD who received dupilumab from March 2018 to June 2019 were included. Demographics, AD severity scores, blood IgE levels, previous atopic keratoconjunctivitis (AKC), dermatological response to dupilumab, ophthalmological evaluation and treatment were noted. Univariate and multivariate analyses were used to identify risk factors for DIOSD.

Results Sixteen of 37 patients who were included in the study (43%) had new or exacerbated symptoms of ocular surface disease starting at 2 weeks following the first treatment. Three patients reported transient dry eye sensation which lasted 2 weeks; nine patients reported chronic dry eye sensation, and four patients (25%) had marked blepharoconjunctivitis. The presence of severe AD was the strongest predictor of DIOSD. Not a single patient with moderate AD had DIOSD. In multivariate analysis, prior AKC was a risk factor for DIOSD (R2=15.78, OR=23.28, p=0.005) while a family history of atopy was protective of DIOSD (R2=6.22, OR=0.13, p=0.05). All four patients with blepharoconjunctivitis had resolution of signs, and symptoms within days of starting periocular 0.03%–۰.۱% tacrolimus ointment.

Conclusions DIOSD is common in patients with AD receiving dupilumab. While most cases are mild, some patients can develop blepharoconjunctivitis which responds well to tacrolimus ointment. AD severity, and previous AKC are risk factors for DIOSD.

Upside-down position leads to choroidal expansion and anterior chamber shallowing: OCT study

Fei Li, Hao Li, Jianlong Yang, et all

Background To determine whether dynamic changes in choroidal thickness (CT) cause shallowing of the anterior chamber.

Methods ۳۴ healthy volunteers were enrolled. The participants in our study adopted the upside-down position for 1.5 min, which was the model we used to study the dynamic changes in CT. Intraocular pressure (IOP) elevation, optical coherence tomography images of the choroid and anterior chamber were obtained at baseline, after being in an upside-down position in an inversion machine and after 15 min of rest. The changes in IOP, anterior chamber and choroidal blood flow between the baseline and the upside-down position were compared.

Results Sixty-eight eyes from 34 subjects were analysed. After being in upside-down position for 1.5 min, there was a significant increase in CT from 226.39±۵۲.۴۴ µm to 238.34±۵۴.۸۴ µm (p<0.001). Choroidal flow index decreased from 0.3357±۰.۰۲۵۱ to 0.3004±۰.۰۱۹۰ in upside-down position, and there was a decrease in anterior chamber depth (3.21±۰.۲۲ mm to 3.13±۰.۲۱ mm, p<0.001) and angle opening distance at 500 µm from the scleral spur (0.65±۰.۲۴ mm to 0.58±۰.۲۰ mm, p=0.007). Pearson correlation analysis showed that the increase in CT was positively related with CT at baseline CT (p=0.001).

Conclusion When the body position changed from sitting to upside-down position, there was choroidal thickening, anterior chamber shallowing and IOP elevation with reduced choroidal blood flow. The data provide evidence about the relationship between choroid expansion and shallowing of the anterior chamber, which may be of relevance for the pathogenesis of angle closure

Central serous chorioretinopathy: risk factors for serous retinal detachment in fellow eyes

Ari Shinojima, Chadi Mehanna, Carlo Alessandro Lavia,et all

Background/Aims To assess risk factors for serous retinal detachment (SRD) in the fellow eye of patients with central serous chorioretinopathy (CSC) based on clinical data and multimodal imaging findings, including baseline late-phase indocyanine green angiography (ICGA).

Methods Consecutive patients with unilateral CSC were retrospectively assessed. Inclusion criteria were the availability of late-phase ICGA and a spectral-domain optical coherence tomography (OCT) macular cube for both eyes at baseline and over 3 months. Subsequent OCT of fellow eyes was reviewed to detect the development of SRD during the follow-up. Baseline medical data and multimodal imaging findings were analysed using Kaplan-Meier survival curves (log-rank test).

Results Sixty-eight patients with unilateral CSC were included. An SRD was detected in 19% of fellow eyes during a mean follow-up of 25.8±۱۸.۷ months. Hyperfluorescent plaques on midphase ICGA, hypofluorescent foci on late-phase ICGA, retinal pigment epithelium changes on fundus autofluorescence and fluorescein angiography abnormalities were associated with the occurrence of SRD (log-rank test; p<0.001, p=0.02, p=0.002 and p=0.001, respectively).

Conclusion These results suggest that the fellow eyes with specific findings on multimodal imaging in patients with unilateral CSC should be carefully followed up for possible incidence of CSC.

Diagnosis and treatment of peripheral exudative haemorrhagic chorioretinopathy

Sarah Vandefonteyne, Jean-Pierre Caujolle, Laurence Rosier. Et all

Purpose Peripheral exudative haemorrhagic chorioretinopathy (PEHCR) is a rare disorder that is often misdiagnosed. The aim of this study was to better characterise PEHCR and to assess treatment options.

Material and methods Retrospective multicentric chart review.

Results Of 84 eyes (69 patients) with PEHCR referred between 2005 and 2017, the most common referral diagnosis was choroidal melanoma (41.3%). Bilateral involvement was found in 21.7% of cases. Haemorrhagic retinal pigment epithelium detachment was the most common peripheral lesion (53.6%). Maculopathy was associated with peripheral lesions in 65.8% of cases. PEHCR lesions were mostly heterogeneous (58.8%) on B-scan ultrasonography. Choroidal neovascularisation was found in 10 eyes (26.3%) out of 38 eyes that underwent fluorescein angiography. Polyps were observed in 14 eyes (58.3%) out of 24 eyes that underwent indocyanine green angiography. Fifty-one eyes were treated (62.2%). Intravitreal injections (IVTI) of antivascular endothelial growth factor (VEGF) were the most used treatment (36.6%) before laser photocoagulation, photodynamic therapy, vitrectomy and cryotherapy. Only vitrectomy improved visual acuity. Most lesions (65.6%) regressed at the last follow-up visit.

Conclusion In case of PEHCR, multimodal imaging is useful to avoid misdiagnosis, to characterise PEHCR lesions and to guide treatment strategies. Regression of PEHCR lesions was observed in two-thirds of the patients. Vitrectomy improved visual acuity. More than a third of patients underwent anti-VEGF IVTI. Further studies are needed to assess IVTI’s efficacy.