Third cranial nerve palsy due to COVID-19 infection

COVID-19-Related Diplopia and Its Treatment

Background and Objectives: The effects of COVID-19 disease can manifest and cause eye complications, one of which is diplopia. Diplopia is a medical condition that makes one object appear like two images. People may also experience diplopia after receiving the COVID-19 vaccine, after contracting COVID-19, or following a COVID-19 infection. Materials and Methods: This review aims to summarize the cases of COVID-19 that can cause diplopia and its treatment in the past 5 years. The literature search databases used for this review were PubMed and Scopus. The keywords used were "diplopia," "COVID-19," and "treatment." Sixteen articles were reviewed after screening and applying the inclusion criteria. Results: The results show that over the past 5 years, cases of diplopia related to COVID-19 have occurred in America, Europe, Asia, and Africa. Most studies are case reports, and the total number of patients was 26, with an age range of 14 to 81. Conclusions: The diplopia cases recovered within 1 day to 8 months. Patients who experienced diplopia after receiving the COVID-19 vaccine, during COVID-19 infection, or after COVID-19 infection exhibited different symptoms. Nasopharyngeal swabs, magnetic resonance imaging (MRI), computerized tomography (CT) scans, visual acuity tests, slit lamp biomicroscope examinations, eye movement tests, funduscopic examinations, and blood tests were the most commonly performed tests. Corticosteroids such as prednisone, methylprednisolone, and prednisolone were the most commonly used drugs to treat diplopia. In addition to corticosteroids, antibiotics, antivirals, antiplatelets, and vitamins were also given. An eye patch was considered to alleviate the diplopia.

Ocular manifestations of COVID-19

There is an increasing body of knowledge regarding how COVID-19 may be associated with ocular disease of varying severity and duration. This article discusses the literature on the ocular manifestations associated with COVID-19, including appraisal of the current evidence, suggested mechanisms of action, associated comorbidities and risk factors, timing from initial infection to diagnosis and clinical red flags. The current literature primarily comprises case reports and case series which inevitably lack control groups and evidence to support causality. However, these early data have prompted the development of larger population-based and laboratory studies that are emerging. As new data become available, a better appraisal of the true effects of COVID-19 on the eye will be possible. While the COVID-19 pandemic was officially declared no longer a "global health emergency" by the World Health Organization (WHO) in May 2023, case numbers continue to rise. Reinfection with different variants is predicted to lead to a growing cumulative burden of disease, particularly as more chronic, multi-organ sequelae become apparent with potentially significant ocular implications. COVID-19 ocular manifestations are postulated to be due to three main mechanisms: firstly, there is a dysregulated immune response to the initial infection linked to inflammatory eye disease; secondly, patients with COVID-19 have a greater tendency towards a hypercoagulable state, leading to prothrombotic events; thirdly, patients with severe COVID-19 requiring hospitalisation and are immunosuppressed due to administered corticosteroids or comorbidities such as diabetes mellitus are at an increased risk of secondary infections, including endophthalmitis and rhino-orbital-mucormycosis. Reported ophthalmic associations with COVID-19, therefore, include a range of conditions such as conjunctivitis, scleritis, uveitis, endogenous endophthalmitis, corneal graft rejection, retinal artery and vein occlusion, non-arteritic ischaemic optic neuropathy, glaucoma, neurological and orbital sequelae. With the need to consider telemedicine consultation in view of COVID-19's infectivity, understanding the range of ocular conditions that may present during or following infection is essential to ensure patients are appropriately triaged, with prompt in-person ocular examination for management of potentially sight-threatening and life-threatening diseases.

Treatment of acquired partial oculomotor nerve palsy with dexamethasone - A case report

INTRODUCTION/IMPORTANCE

Oculomotor nerve palsy is an acquired condition caused by injury to the third cranial nerve. Patients present classically with their eye in a "down and out" positioning, ptosis and abnormalities in most extraocular movements causing diplopia. Ocular dysfunction may be due to a variety of different etiologies, such as aneurysm, microvascular disease, trauma, and viral infections. Clinical prognosis is usually quite good and is often self-limiting.

CASE REPRESENTATION

We present a case of an otherwise healthy 40-year-old male who awoke one morning with moderate diplopia, unable to focus with binocular vision and developed eyelid ptosis two days later. He was previously infected with the Omicron variant of COVID-19; however, a rapid test could not confirm it. No intracranial or vascular pathology were identified on CT head, CT angiogram, or MRI. Repeat COVID-19 PCR test was negative. He was assessed by a neuro-ophthalmologist and was diagnosed with left partial oculomotor nerve palsy presumed secondary to viral microvascular injury. COVID-19 infection seemed likely given the history but could not be confirmed. The specialist recommended monitoring the patient without any treatment, with no recommendation of corticosteroid use.

CLINICAL DISCUSSION

Cranial neuropathy guidelines for viral palsies involving the 7th or 8th cranial nerve are treated with corticosteroids. After considering the risks, the patient elected treatment with a left eye patch and a dexamethasone taper. Full return of function in all extremes of gaze was restored less than 2 months after onset.

CONCLUSION

Given the complete and timely recovery, it may be reasonable to consider corticosteroids for all cranial neuropathies.