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NEW ORLEANS -- While pink eye may get the most attention, it's far from the only eye abnormality linked to COVID-19, eye doctors told colleagues here at the annual meeting of the American Academy of Ophthalmology (AAO).

A new literature review identified a long list of possibly related neuro-ophthalmic/retina conditions such as photophobia, retinal hemorrhage, and optic neuritis, while Indian researchers highlighted a series of dangerous eye infections linked to diabetes and steroid use.

"We are entering a new era where discussion about eye side effects is important in COVID," review co-author Gloria Wu, MD, a retina specialist at the University of California San Francisco, told MedPage Today. "At first, we thought about conjunctivitis. Now, we are seeing long-COVID patients who are showing neuro-ophthalmic symptoms. I see a lot of patients who have had COVID and complain of headaches and a subtle inability to read for more than 15 minutes."

Wu's literature review, which was presented at the AAO meeting, identified 30 reports of potentially COVID-19-related neuro-ophthalmic/retina conditions in about 3,000 subjects. Of those whose gender was identified, 977 were males, and 876 were females. Manifestations included facial palsy, headache, and optic neuritis. Photophobia and sore eyes were also reported, as were retinopathy, retinal hemorrhage, cotton wool spots, and diabetic retinopathy, among others.

According to Wu, some eye manifestations are related to sequelae of COVID-19. "A COVID patient develops meningitis, and their eyes will have neuro-ophthalmic changes: ptosis, eye muscle movements, eye fatigue. If the COVID patient gets [arrhythmia] and goes on amiodarone, they may get corneal verticillata, a corneal side effect."

The pathophysiology of eye manifestations of COVID-19 are unknown, she said. The virus does affect the clotting cascade, she said, "but why it would cause meningitis with subsequent ophthalmic sequela is still unknown. We do not have biopsies or tissue reports or pathology specimens to identify COVID virus in the eye -- retina, extraocular muscles, etc."

Wu also noted that she and her colleagues have been bombarded with calls about herpes zoster, which she attributes to immune systems weakened by pandemic stress/anxiety.

A case series presented at AAO pointed to another possible ocular manifestation of COVID-19: rhino-orbital-cerebral mucormycosis (ROCM), a potentially fatal invasive disease in people with diabetes.

Ophthalmologist Mrittika Sen, MD, of the Centre for Sight Superspecialty Eye Hospital in Hyderabad, India, and colleagues reported on six men with type 2 diabetes and COVID-19 (average age 60.5, five of whom were taking systemic steroids) who developed ROCM.

"ROCM is a life-threatening opportunistic infection. Patients with moderate-severe COVID-19 with uncontrolled diabetes and receiving steroids are susceptible to it during the illness or as a sequelae," the researchers wrote. The patients, who were alive as of follow-up, were treated with IV liposomal amphotericin B plus posaconazole, surgical debridement of necrotic tissue, and functional endoscopic sinus surgery.