Concurrent tonic pupil and trochlear nerve palsy in COVID-19

Abstract

Since COVID-19 was first reported, different neurological complications have been acknowledged, but their description is constantly evolving. We report a case of concurrent tonic pupil and trochlear nerve palsy in this context. A 62-year-old man reported a 5-day history of binocular vertical diplopia and blurred vision in his left eye, noticing that his left pupil was dilated. He had suffered a flu-like syndrome 2 weeks before. Clinical exam showed a right trochlear nerve palsy and a left mydriatic pupil. MRI, X chest ray, and analytical results were normal. Antibodies for SARS-CoV-2 were positive (low IgM and high IgG titers). Antiganglioside antibodies were negative. A 0.125% pilocarpine test confirmed Adie's pupil diagnosis. The patient was treated with a tapered prednisone dose with resolution of his diplopia but no change in Adie's pupil. This is the first case reporting Adie's pupil as a postinfectious manifestation of COVID-19. An immune-mediated mechanism is presumed.

Evidence of SARS-CoV-2 Transmission Through the Ocular Route

“… 29 Rare ocular symptoms including episcleritis, panuveitis, optic neuritis, retinal vascular diseases, cranial neuropathies, Miller Fisher syndrome, and Adie’s syndrome have also been reported. 30–34 …”

Adie-Holmes syndrome associated with COVID-19 ınfection

“…reported SARS-CoV-2 related unilateral tonic pupil accompanying cranial neuropathy, 3 weeks after COVID-19 infection. [ 3 ] Most recently, Seller et al . reported SARS-CoV-2 related inflammatory chorioretinopathy and bilateral Adie's syndrome two days after the onset of respiratory symptoms.…”

“…Taper prednisolone was also chosen in Adie's pupil due to COVID-19, which was considered as a delayed immune response, and a regression in neurological complaints was observed. [ 3 ]…”

“…[ 1 ] Most recently, pupillary involvement associated with this virus has been reported. [ 2 3 4 ] Here, we report a further case of a possible COVID-19-related tonic pupil manifested by blurred vision.…”

Internuclear ophthalmoplegia as a presenting feature in a COVID-19-positive patient

“…12 Reports of neuro-ophthalmic findings such as cranial nerve paresis, optic neuritis, gaze palsy, vision loss and so on are being increasingly described in the literature. [6][7][8][9][10][11][12][13][14][15][16] Multiple mechanisms in the aetiopathogenesis of neuroophthalmic manifestations in COVID-19 have been proposed, and these include postviral inflammatory syndrome, sequelae of a proinflammatory state and as a consequence of systemic conditions, such as cardiovascular disease or uncontrolled hypertension. 14 Haematological spread and direct viral invasion have also been suggested.…”