Ocular Assessments of a Series of Newborns Gestationally Exposed to Maternal COVID-19 Infection

The influence of SARS-CoV-2 spike protein exposure on retinal development in the human retinal organoids

BACKGROUND

Pregnant women are considered a high-risk population for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, as the virus can infect the placenta and embryos. Recently, SARS-CoV-2 has been widely reported to cause retinal pathological changes and to infect the embryonic retina. The infection of host cells by SARS-CoV-2 is primarily mediated through spike (S) protein, which also plays a crucial role in the pathogenesis of SARS-CoV-2. However, it remains poorly understood how the S protein of SARS-CoV-2 affects retinal development, and the underlying mechanism has not yet been clarified.

METHODS

We used human embryonic stem cell-derived retinal organoids (hEROs) as a model to study the effect of S protein exposure at different stages of retinal development. hEROs were treated with 2 μg/mL of S protein on days 90 and 280. Immunofluorescence staining, RNA sequencing, and RT-PCR were performed to assess the influence of S protein exposure on retinal development at both early and late stages.

RESULTS

The results showed that ACE2 and TMPRSS2, the receptors facilitating SARS-CoV-2 entry into host cells, were expressed in hEROs. Exposure to the S protein induced an inflammatory response in both the early and late stages of retinal development in the hEROs. Additionally, RNA sequencing indicated that early exposure of the S protein to hEROs affected nuclear components and lipid metabolism, while late-stages exposure resulted in changes to cell membrane components and the extracellular matrix.

CONCLUSION

This work highlights the differential effects of SARS-CoV-2 S protein exposure on retinal development at both early and late stages, providing insights into the cellular and molecular mechanisms underlying SARS-CoV-2-induced developmental impairments in the human retina.

The pregnancy outcomes of women with SARS-CoV-2 infection in the first trimester ---a longitudinal cohort study

BACKGROUND

In recent years, severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) infection has been prevalent worldwide. Pregnant women belong to a special group, and it is very important for clinicians to pay attention to the impact of SARS-CoV-2 infection on pregnancy outcomes. However, there are limited studies on the impact of SARS-CoV-2 infection on pregnancy outcomes during the first trimester.

OBJECTIVE

To investigate the effect of SARS-CoV-2 infection in the first trimester on pregnancy outcomes.

METHODS

Clinical information of pregnant women whose last menstrual period was between October 1, 2022, and April 1, 2023, and who were registered in the Obstetrics and Gynecology department of Peking University International Hospital, was analyzed. Among them, 498 pregnant women with SARS-CoV-2 infection in the first trimester were included in the study group; while a total of 654 pregnant women with no SARS-CoV-2 infection in the first trimester were included in the control group. Mann Whitney U test, χ2 test, Fisher's exact probability method, and multivariate logistic regression were used to analyze the impact of SARS-CoV-2 infection on pregnancy outcomes during the first trimester.

RESULTS

A total of 30 cases in the study group experienced pregnancy loss before 28 weeks of gestation, and 468 cases delivered. In the control group, 41 cases experienced pregnancy loss before 28 weeks of gestation, and 613 cases delivered. The rates of pregnancy loss in the two groups were 6.02% and 6.27%, respectively, with no statistically significant difference between the two groups (P > 0.05). There was no statistically significant difference (P > 0.05) in the baseline data (delivery age, pre-pregnancy body mass index, gestational age, and parity) between the two groups. The rates of neonatal malformation, premature birth, premature rupture of membranes, postpartum hemorrhage, cesarean section, small for gestational age infants, low birth weight infants, macrosomia, and neonatal asphyxia were compared, with no statistically significant difference between the two groups (P > 0.05). However, the incidence of gestational hypertension in the study group was significantly higher than that in the control group (P = 0.012).

CONCLUSIONS

In this single center study, we found that SARS-CoV-2 infection in the first trimester may increase the risk of gestational hypertension, while the incidences of other adverse pregnant outcomes such as premature birth, premature rupture of membranes, cesarean section, postpartum hemorrhage, small for gestational age infants, low birth weight infants, and neonatal asphyxia did not significantly increase compared with women without SARS-CoV-2 infection in the first trimester.

External Disruption of Ocular Development in Utero

The intricate steps of human ocular embryology are impacted by cellular and genetic signaling pathways and a myriad of external elements that can affect pregnancy, such as environmental, metabolic, hormonal factors, medications, and intrauterine infections. This review focuses on presenting some of these factors to recognize the multifactorial nature of ocular development and highlight their clinical significance. This review is based on English-language articles sourced from PubMed, Web of Science, and Google Scholar; keywords searched included "ocular development in pregnancy," "ocular embryology," "maternal nutrition," "ophthalmic change," and "visual system development." While some animal models show the disruption of ocular embryology from these external factors, there are limited post-birth assessments in human studies. Much remains unknown about the precise mechanisms of how these external factors can disrupt normal ocular development in utero, and more significant research is needed to understand the pathophysiology of these disruptive effects further. Findings in this review emphasize the importance of additional research in understanding the dynamic association between factors impacting gestation and neonatal ocular development, particularly in the setting of limited resources.

A Systematic Literature Review and Bibliometric Analysis of Ophthalmology and COVID-19 Research

This review is proposed to summarize the updates on COVID-19 and ophthalmology along with the bibliometric features of articles that have been published since the beginning of the COVID-19 outbreak. The databases, including PubMed, Scopus, and Web of Science, were searched using "Coronavirus," "COVID-19," "SARS-CoV-2," "pandemic," "ophthalmology," "ophthalmic," and "eye" keywords. All published articles except commentaries, errata, and corrigenda up to April 2021 were included. Titles and abstracts were screened, and ophthalmology-focused articles were collected. The bibliographic information of the articles, such as the name and country of the first author, type of study, date of publication, language, and journal name, were extracted. Included studies were assessed using the Joanna Briggs Institute (JBI) critical appraisal checklist. After systematic searching, 2,669 distinct articles were screened by title/abstract, and 1,174 ophthalmology-focused articles were selected to be reviewed. Ophthalmology-focused publications accounted for less than 0.5 percent of the total COVID-19-related articles. Most of the articles were published in the Indian Journal of Ophthalmology, and the main publication type was "original article." Almost 88% of the publications were in English. There was a decline in the publication rate during the initial months of 2021 compared with the middle and last months of 2020. Most of the publications were affiliated with the United States of America. However, Singapore and the United Kingdom were the countries with the highest number of publications after population adjustment. Furthermore, a comprehensive review on major topics including SARS-CoV-2 ocular tropism, ophthalmic manifestations, ocular complications due to COVID-19 treatment strategies, the pandemic effect on ophthalmology care and operations, myopia progression during the pandemic, and telemedicine was conducted.

Retinal Findings of Hospitalized Neonates Recovered from COVID-19 Infection: A Prospective, Observational, Descriptive Study

PURPOSE

Coronavirus disease 2019 (COVID-19) that is caused by severe acute respiratory syndrome coronavirus 2 can cause microvascular alterations that can lead to irreversible complications in multiple tissues and organs. Detrimental effects of COVID-19 on retinal structure have recently been reported in adult population. However, literature data about neonatal population is very scarce. Thus, we aimed to assess possible retinal changes of neonates recovered from COVID-19 infection in this prospective, observational, descriptive study.

METHODS

The neonates recovered from COVID-19 infection were included to the study between 01 September 2020 and 30 April 2021. Their initial ophthalmological examination was made after a negative real-time reverse transcription-polymerase chain reaction obtained and all patients were re-examined 1 month later. All examinations were performed by same retina specialist using a binocular indirect ophthalmoscopy.

RESULTS

A total of 15 neonates [9 (60%) male, 6 (40%) female, mean gestational age of 38.9 ± 0.9 weeks (ranging from 37 to 40 week)] were evaluated in the study. The mean age at the time of hospitalization was 17.5 ± 8.7 days (ranging from 2 to 29 days), and the mean duration of hospitalization was 12.5 ± 6.2 days (ranging from 4 to 27 days). Except for one patient with bilateral avascular area in Zone-III, no further retinal manifestation related to COVID-19 was found in the study.

CONCLUSION

COVID-19 infection can cause retinal damage in neonates. Therefore, these patients should be closely monitored for signs of ocular involvement.

Ocular and Systemic Complications of COVID-19: Impact on Patients and Healthcare

There is increasing information available about the effects of the SARS-CoV-2 virus on the systemic and ocular health of patients, as well as the effects of delayed health care. This mini-review summarizes the potential complications and treatments of COVID-19. Systemic findings include respiratory illness, risk of thromboembolic events, and neurologic findings. Some patients may develop persistent symptoms even after the infection resolves. Effective treatment options include glucocorticoids, antivirals, interleukin-6 antagonists, monoclonal antibodies, Janus kinase inhibitors and vaccines. Potential ocular findings of COVID-19 include conjunctivitis, cranial nerve palsies, and microvascular changes in the retina; most symptoms resolved over time. During the lockdown periods, teleophthalmology was utilized to triage non-urgent issues; patients who did present to emergency departments tended to have more severe disease with worse visual prognoses. While transient delays in outpatient ophthalmic care may be tolerated in some patients, others experienced significant vision loss with interruptions in treatments. Resumption of ophthalmic care as soon as possible may help mitigate the effects of delayed care due to the pandemic.

Ocular manifestations of COVID-19

COVID-19 is a disease caused by a SARS-CoV-2 viral infection, a disease that was first detected in December 2019 in Wuhan, Hubei Province, China. COVID-19, formerly known as 2019 Novel Coronavirus (2019-nCoV) respiratory disease, was officially named COVID-19 by the World Health Organization (WHO) in February 2020. By 25 May 2021, there were 33,579,116 confirmed cases with 599,109 COVID-19 deaths worldwide. The purpose of this review article is to provide an update on what is currently known about COVID-19 ocular symptoms in adults, the elderly, and children in the literature. Finally, this article will review the eye protection precautions that should be implemented in our clinics. To assess the current literature, PubMed was searched from December 2019 to 25 May 2021. Randomized trials, observational studies, case series or case reports, letters of research, and letters to editors were selected for confirmed cases of COVID-19. According to current scientific literature since the outbreak in December 2019, 205 articles have been published. Conjunctivitis, conjunctival hyperemia, and chemosis have been reported in adults with COVID-19. There have been few studies on children and elderly patients, and further research in these age groups is needed. Finally, wearing eye protection when seeing patients on a daily basis during the pandemic is essential.

Short- and mid-term multidisciplinary outcomes of newborns exposed to SARS-CoV-2 in utero or during the perinatal period: preliminary findings

The long-term outcomes of newborns exposed to SARS-CoV-2 infection in utero or during the first hours of life are still unknown. We performed a single-center, prospective, observational study of newborns born from mothers with microbiologically confirmed SARS-CoV-2 infection in pregnancy or at time of delivery. Infants were offered a multidisciplinary follow-up consisting of nasopharyngeal Polymerase Chain Reaction test at birth and at 48-72 h of life, auxological growth and neurological development, serologic testing, and audiological and ophthalmological assessments. One-hundred ninety-eight mothers and 199 newborns were enrolled. Of the 199 newborns, 171 underwent nasopharyngeal swab, four (2.3%) and two (1.15%) children tested positive at birth and 48-72 h of life, respectively. None had SARS-CoV-2 related symptoms. Auxologic and neurologic development were normal in all children during follow-up. Nine out of 59 infants had SARS-CoV-2 IgG at 3 months of life, which was associated with a positive nasopharyngeal swab at birth (P = 0.04). Twenty seven out of 143 (18.8%) newborns had pathologic transitory evoked otoacoustic emissions at birth, although 14/27 repeated after 1 month were normal. Audiological evaluation was completed with Auditory Brainstem Response between the third and sixth month of life in 34 children, showing in all normal hearing threshold. The ophthalmological evaluation found retinal vascular anomalies in 3/20 (15%) children, immature visual acuity in 5/20 (25%) children, and reduced distance attention in 6/20 cases (30%).

CONCLUSIONS

Our study showed that the neonatal and mid-term multidisciplinary outcomes of newborns exposed to SARS-CoV-2 infection in utero or during the first hours of life are mostly positive, with the exception of ophthalmologic findings which, in a preliminary cohort, were abnormal in about 15% of cases. Further prospective, longitudinal studies are needed to better understand the clinical outcomes of children exposed to SARS-CoV-2 in utero and in the early postnatal life.

WHAT IS KNOWN

• In utero mother-to-child transmission of SARS-CoV-2 has been documented by several independent studies. • Neonatal COVID-19 is a systemic disease that can be severe, although rarely.

WHAT IS NEW

• Newborns exposed in utero to SARS-CoV-2 have mostly a normal auxological, audiological, and neurological development during the first months of life. • Fundus fluorescein angiography revealed that up to 5% of newborns exposed in utero to SARS-CoV2 can show retinal and choroidal abnormalities, including peripheral hypofluorescence of the choroid and increased vascular tortuosity.