Neuro-Ophthalmic Complications of COVID-19

A myriad of Neuro-ophthalmic complications have been described in association with COVID-19 infection since the first cases in late 2019. These have included a number of cases of diplopia from cranial neuropathy, including in the setting of Miller Fisher syndrome and myasthenia gravis. Cortical vision loss may result from COVID-19 related infarction or hemorrhage of the occipital lobe or post-geniculate pathways, venous sinus thrombosis, posterior reversible leukoencephalopathy syndrome (PRES) or acute disseminated encephalomyelopathy (ADEM). Optic nerve disease appears to be rare, but cases of optic neuritis, including in association with anti-myelin oligodendrocyte glycoprotein (MOG) antibodies, papillophlebitis and pseudotumor cerebri syndrome related to the pediatric multisystem inflammatory syndrome have been reported. Mechanisms for these neurological syndromes may include direct invasion by the SARS-CoV- 2 virus, permitted by hematogenous spread or possibly, olfactory bulb invasion. However, a para-infectious hypercoagulable state and para- and post-infectious autoimmune diseaseappear to be common mediators of neurological and Neuro-ophthalmic manifestations. It should be understood that some Neuro-ophthalmic symptoms reported in association with COVID-19 may be coincidental or reflect decompensation of existing disease, rather than direct causation related to the infection. Our understanding of the neurological complications of COVID-19 is expanding on a daily basis and will no doubt have changed between this writing and the oral presentation.