Considerations for the Treatment of Inflammatory Neuro-Ophthalmologic Disorders During the COVID-19 Pandemic

Abstract

: The initiation and continuation of immune-based therapies to treat and prevent complications of inflammatory neuro-ophthalmologic disorders during the 2019 novel coronavirus (COVID-19) pandemic is the subject of considerable debate. In each case, a treatment decision must be reached based on best clinical practices for the disorder, patient comorbidities, the current state of knowledge about the pathogenesis and infectivity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and the utilization of hospital and community resources. Unfortunately, the evidence needed to standardize the decision-making process for each neuro-ophthalmologic disorder is currently absent and is likely to require months or years to develop based on the accrual of robust international data sets. In this article, we review the current understanding of SARS-CoV-2 and COVID-19 complications to provide a framework for approaching the treatment of inflammatory neuro-ophthalmic disorders during the COVID-19 viral pandemic.

SARS-CoV-2 Impairs Vision

“…Current data provide evidence that vision in SARS-CoV-2–infected patient can be impaired at several levels (Table 1) (3–23). Ocular causes of impaired vision were more frequent than CNS causes (Table 1).…”

“…However, if the retina and the optic nerve were regarded as part of the CNS, CNS abnormalities were more frequently responsible for impaired vision in COVID-19 patients. Neuro-ophthalmologic causes of visual impairment detected included dacryoadenitis, conjunctivitis, tonic pupils, myasthenia, vitritis, central retinal artery occlusion/central retinal venous occlusion (CRAO/CRVO), retinitis, retinal ganglion cell dysfunction, retinal bleeding, panuveitis, anterior, ischemic optic neuropathy (AION), optic nerve stroke, optic neuritis, optic perineuritis, ischemic stroke, sinus venous thrombosis (SVT), and posterior reversible encephalopathy syndrome (3–23). Thus, impaired vision due to SARS-CoV-2 is multicausal and multilocular.…”

“…Conjunctivitis, on the contrary, has been much more frequently reported as a complication of COVID-19 and is probably the most frequent ophthalmologic complication of COVID-19 (4). Since myasthenia exacerbates in about half of the patients with a SARS-CoV-2 infection, it is comprehensible that double vision or blurred vision may evolve (6). Vitritis as a complication of COVID-19 has been reported in only 2 patients so far (7,23).…”

Should Immunosuppressive Therapy Be Modified During a Pandemic?

“…It is an understandable assumption that patients receiving immunosuppressive treatments are likely to be more susceptible to contracting and experiencing poor outcomes from infectious diseases (1). However, many steroid-sparing immunosuppressants do not seem to confer significant risk of a poor outcome from COVID-19 infection (2)(3)(4).…”