Ophthalmic Side Effects of COVID-19 - A Novel Case from the Coronavirus Pandemic

As part of Med-Challenger's Guideline Knowledge Check blog series, we sometimes like to address unusual cases where medical problems may become more prevalent given certain circumstances, like during a viral pandemic. An increase in certain acute ophthalmic problems during the COVID-19 pandemic is a great example. Try this case involving ophthalmic side effects of the coronavirus pandemic.

Today’s Guideline Knowledge Check question comes from the desk of Med-Challenger Emergency Medicine Editor-in-Chief, Andrea Eberly, MD, FAAEM.

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The COVID-19 Pandemic leads to an increase in acute ophthalmic problems that do not immediately appear related to the pandemic. What are these significant ophthalmic side effects?

Two adult males, ages 35 and 22 years old, present together via EMS to an emergency department at 2 am with intense eye pain and photophobia. Both also reported foreign body sensations in their eyes.

The pain started during the afternoon, when they were at their respective work-places, and became too intense to bear during the night. Nobody else at either workplace has developed symptoms. One patient works at a grocery store in the ordering department, the other patient works at a hospital as a lab technician.

Both deny trauma, or any other unusual exposures of their eyes, eg. to chemicals, welding, insects, or other irritating objects or events. The more severely affected patient wears corrective contact lenses at night for mild myopia; both deny any other ophthalmic history.

Both state that their vision is normally 20/20, but currently is slightly blurred. In the previous 5 days, both attended a party together with a friend who has since tested positive for SARS-CoV-2. Both patients deny COVID-19 symptoms.

An exam shows significant lid spasm, conjunctival injection, significant photophobia, and pronounced bilateral tearing in both patients. Both patients can read a hand-held vision card down to the 25/20 line.

Extraocular movements are intact; the pupils are constricted but reactive. Seidel test is negative and eye pressures are normal.

A slit lamp exam reveals conjunctival injection and punctate corneal lesions in all 4 eyes (see image); there is no hypopyon or bleeding noted; the retinas of all 4 eyes appear normal.

The lids are edematous, but show no signs of infection.

ophthalmic side effects covid-19 eye pain

Question:

What is the diagnosis and how is it related to SARS-CoV-2?

Answer Options:

Infectious keratitis due to aerosol-induced ophthalmic contact with SARS-CoV-2.

Inflammatory keratitis due to local auto-immune reaction to ophthalmic entry of SARS-CoV-2.

Infectious keratitis due to upward migration of nasopharyngeal SARS-CoV-2 into eyes rather than classic downward migration into oropharynx.

UV-keratitis; related to indoor exposure to UV-lights that are set up to eliminate SARS-CoV-2 from an indoor space.

See the Answer:

The correct answer is:

UV-keratitis; related to indoor exposure to UV-lights that are set up to eliminate SARS-CoV-2 from an indoor space.

Key Point:

Given the sensitivity of SARS-CoV-2 to UV light, businesses in particular are attempting to sterilize their indoor spaces by adding artificial UV-lights.

This has led to a COVID-19-related increase in “Welder’s keratitis” (UV-keratitis) in the absence of any of the classically known causes (welding, extended exposure to sunlight, tanning beds) - ophthalmic side effects of the coronavirus pandemic response environment.

Thus, a new question needs to be asked: “Have you been exposed to UV-lights that, for example, were set up to eliminate the coronavirus?”

Explanation:

The above case occurred after the two patients had received a haircut at the same hair salon, which had just reopened on that day after several months of COVID-19 related closure.

The owner had heard that UV-light kills the virus and had installed his usual UV light, normally used for sterilizing his instruments, overhead above his salon chairs.

UV-keratitis is due to the fact that UV-light, different from light of other wavelengths, does not pass through the cornea but is absorbed by the corneal cells. An overexposure will kill the corneal cells, leaving punctate ulcers.

The goal of ultraviolet (UV) keratitis therapy is to treat the pain associated with damage in the corneal epithelium resulting from UV light exposure and to prevent infection while the cornea heals. Some medications include ophthalmic antibiotics, topical cycloplegics, ophthalmic anesthetics, ophthalmic and parenteral nonsteroidal anti-inflammatory drugs (NSAIDs), and other analgesics.

The above patients were initially treated with ophthalmic levofloxacin, artificial tears, and ophthalmic pain medication. At 72 hours, an eye ointment with vitamin A was added to support healing of several small, remaining ulcers. The patients experienced complete resolution of the keratitis at 84 hours post-exposure.

Long-term, UV-over-exposure leads to cataracts, pterygiums, and ophthalmic melanoma, and non-melanotic malignancies.

Reference:

Röper, Kristin et al. “Massive Augenschmerzen beidseits – Kurioser Fall in Zeiten der Corona-Pandemie” [Massive bilateral eye pain - Unusual case in times of the coronavirus pandemic]. Der Ophthalmologe : Zeitschrift der Deutschen Ophthalmologischen Gesellschaft vol. 117,10 (2020): 1041-1044. doi:10.1007/s00347-020-01201-7

Eye. Elk Grove Village: American College of Occupational and Environmental Medicine (ACOEM); 2004. 77 p.

Finn LE, Gutowski J, Alles S, Mirowitz N, Johnson C, Osterhoudt KC, et al. Photokeratitis Linked to Metal Halide Bulbs in Two Gymnasiums - Philadelphia, Pennsylvania, 2011 and 2013. MMWR Morb Mortal Wkly Rep. 2016 Mar 25. 65 (11):282-5.

Daxecker F, Blumthaler M, Ambach W. Ultraviolet exposure of cornea from sunbeds. Lancet. 1994 Sep 24. 344(8926):886.

Koyfman A. What-is-the-role-of-medications-in-the-treatment-of-ultraviolet-keratitis (updated March 14, 2019) (Accessed October 15, 2020)

Ophthalmic side effects of Covid-19, Environmental Medicine. Ophthalmic side effects related to the coronavirus pandemic

Ophthalmic Side Effects of COVID-19 - A Novel Case from the Coronavirus Pandemic - UV-keratitis

About Guideline Knowledge Checks:

With each update of national clinical practice guidelines, some recommendations change and many remain unchanged. Med-Challenger Guideline Knowledge Checks help you know both what is new and what has stayed the same in the most recent guidelines pertinent to each medical specialty.

About the Author:

Andrea Eberly, MD, FAAEM graduated from the David Geffen Medical School of Los Angeles (UCLA) and completed her residency in Emergency Medicine at the University Medical Center, Tucson, Arizona. After working as an attending physician in Tucson, she followed a recruiting call to the island of Guam, where she served in various roles, including as the director of the emergency department, the EMS Medical Director of Guam, and the Director of the 911 Call System. She has maintained her emergency medicine board certification through three cycles of American Board of Emergency Medicine Board Exams (last in 2014), all three with the help of Med-Challenger.

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