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 Table of Contents  
Year : 2022  |  Volume : 36  |  Issue : 3  |  Page : 106-111

Ocular manifestations in post-coronavirus disease-2019 patients in a tertiary care institute in North-East India: A cross-sectional study

1 Department of Ophthalmology, Jawaharlal Institute of Medical Sciences, Imphal, Manipur, India
2 Department of Respiratory Medicine, Jawaharlal Institute of Medical Sciences, Imphal, Manipur, India
3 Department of Community Medicine, Jawaharlal Institute of Medical Sciences, Imphal, Manipur, India

Date of Submission24-Sep-2022
Date of Decision05-Nov-2022
Date of Acceptance13-Dec-2022
Date of Web Publication25-Feb-2023

Correspondence Address:
Dr. Rajkumari Bishwalata
Department of Community Medicine, Jawaharlal Institute of Medical Sciences, Imphal - 795 005, Manipur
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jms.jms_75_22

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Background: There are various studies on coronavirus disease-2019 (COVID-19) from globally which are mainly focused on respiratory and other medical manifestations of the disease. There are few studies on ocular manifestations in COVID-19 and post-COVID-19 patients.
Objectives: We aim to investigate the ocular manifestations of hospitalized post-COVID-19 patients at a tertiary care institute in the North Eastern part of India.
Materials and Methods: This cross-sectional study was conducted among hospitalized post-COVID-19 patients 18 years and above during July 1, 2021–December 31, 2021. A universal sampling method was employed. A structured pro forma was used for data collection along with detailed ocular examination. Descriptive statistics were generated from collected data. Approval of the study was obtained from the institutional ethics committee.
Results: A total of 105 patients were included in the study with ages ranging from 18 to 85 years and males constituting 63.8%. Around two-thirds of the patients (70, 66.7%) had not received any vaccination. Chest X-ray showed bilateral moderate consolidation in 59 (56.2%) patients. Twelve (11.4%) patients developed ocular signs and symptoms. Dry eye, redness of the eye, dimness of vision, itching, blurring of vision, and discharge from the eyes are some of the symptoms encountered. Two patients developed subconjunctival hemorrhage, one patient had a retinal hemorrhage and exposure keratopathy was detected in one patient.
Conclusion: In this study, 11.4% of hospitalized post-COVID-19 patients have ocular manifestations. Post-COVID-19 syndrome could affect the eyes thus necessitating meticulous follow-up of patients who recovered from COVID-19.

Keywords: Manifestations, ocular, postcoronavirus disease-2019

How to cite this article:
Rajkumari B, Rajkumar V, Chingakham DS, Bishwalata R. Ocular manifestations in post-coronavirus disease-2019 patients in a tertiary care institute in North-East India: A cross-sectional study. J Med Soc 2022;36:106-11

How to cite this URL:
Rajkumari B, Rajkumar V, Chingakham DS, Bishwalata R. Ocular manifestations in post-coronavirus disease-2019 patients in a tertiary care institute in North-East India: A cross-sectional study. J Med Soc [serial online] 2022 [cited 2023 Jun 9];36:106-11. Available from:

  Introduction Top

Coronavirus disease-2019 (COVID-19) disease caused by the highly transmissible severe acute respiratory syndrome virus-2 (SARS-CoV-2) is one of the biggest pandemics in the history of humankind[1] leading to serious morbidity and mortality worldwide.[2],[3],[4]

COVID-19 deprives the entire body of oxygen, including the brain and this can cause complications in various parts of the body including the eye.[5] Inflammatory syndrome is associated with COVID-19 in more severe cases, most often in persons with severe comorbidities.[6],[7],[8] The pathophysiology behind ocular manifestations of COVID-19 includes theories such as direct inoculation of the virus to ocular tissues from respiratory droplets or aerosolized viral particles, migration from the nasopharynx via nasolacrimal duct and hematological spread.[9] A person who had COVID can shed the virus through their tears, sometimes long after they have recovered from the illness.[10]

Ocular manifestations could be the earliest symptom to appear in COVID-19.[11] Various ocular manifestations of COVID-19 have been reported worldwide which involve structures of the eye such as eyelids, conjunctiva, cornea, episcleral, sclera, retina, and cranial nerves. Conjunctivitis can be the first sign and symptom of COVID-19.[12] Retinal complications may include retinal arteritis, retinal arteries and vein occlusion, and cotton wool spots.[13] Blood clots in the retinal arteries can block the flow of oxygen causing the cells to die leading to painless loss of vision.[14]

Long COVID is a post-COVID-19 condition where long-term symptoms develop following the illness.[15] Post-COVID-19 patients may develop symptoms related to dry eye diseases such as itching, blurred vision, pain, or burning sensation in the eyes.[16] Some patients experience changes in vision with blurred vision, light sensitivity, eyeache, and difficulty in focusing and may experience more than one ocular sign and symptom.[17] Patients who received any form of supplementary oxygen during hospitalization may develop dry eye and exposure keratopathy.[18] The gas inflow from oxygen delivery may increase the evaporation of the tear film leading to dry eye. A loose mask lets air flow directly toward the eyes and evaporates the tears causing dry eyes.[19] This together with inappropriate closure of eyes may lead to exposure keratopathy.[20] COVID-19 disease blocks or restricts blood supply to the retina in some patients resulting in retinopathy, leading to visual impairment and bleeding in the retina. Retinopathy begins to occur between 2 and 6 weeks after the patient recovered from COVID-19.[21] Thus, this study was taken up to investigate the ocular manifestations of hospitalized post-COVID-19 patients in a tertiary care institution.

  Materials and Methods Top

This cross-sectional study was done among patients admitted in the post-COVID ward from July 1, 2021, to December 31, 2021, in a tertiary care institute in the Northeastern part of India. The study population comprises patients 18 years and above who had a positive reverse transcription–polymerase chain reaction (RTPCR) on the nasopharyngeal swab for COVID-19, and became RTPCR-negative, but admitted to the post-COVID ward due to various health conditions or complications. Refusals to participate were excluded from the study.

Sample size and sampling

Universal sampling was done for all patients fulfilling the inclusion criteria admitted in the post-COVID ward during from July 1, 2021, to December 31, 2021.

Study tool and technique

A structured pro forma was developed after extensive literature review for data collection. The study tool was peer reviewed by two expert specialists and was pretested on a group of patients after which necessary modifications were made before arriving at the final version. The different sections included in the study tool were the sociodemographic profile, history of exposure history to COVID-19, presence of systemic symptoms and systemic illness, ocular manifestations and symptoms, finding of ocular examination, and treatment of ocular symptoms and disposition. Data collection was done after obtaining informed consent from each respondent. A detailed ocular examination was performed by an ophthalmologist for all cases with eye manifestations and complaints. Visual acuity was taken using Snellen chart and refraction was done wherever indicated; a detailed slit-lamp examination of the anterior segment was performed. Fundoscopy was done by indirect ophthalmoscopy and photographs were taken using fundus camera wherever identified.

Statistical analysis

All collected data were entered into Microsoft Excel sheet and data cleansing was performed. Data analysis was done using IBM SPSS version 20 (IBM company, Chicago, Illinois, United States). Descriptive statistics such as mean standard deviation (SD) and percentages were generated for the study.

Ethical considerations

Approval of the institutional ethics committee was obtained for this study vide Proposal No. 306/23/21. All identifiers were removed from collected data and strict confidentiality was maintained.

  Results Top

A total of 105 patients were included in the study. The age of the patients ranges from 18 to 85 years with a mean (SD) age of 62.4 ± 14.1 years. Males constituted 63.8% and the majority were Hindu (55, 52.3%) by religion [Table 1]. The majority of the patients were admitted with complaints of shortness of breath (79%), cough (62%), fever (50.5%), and generalized weakness (43.8%). Altered sensorium was complained by 3.8% of patients. The majority of the patients have more than one complaint.
Table 1: Sociodemographic profile of the respondents (n=105)

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The most common ocular problem was redness of the eye found in 5 (4.7%) of patients, followed by foreign body sensation in 3 (2.9%), blurring of vision, itching of eyes in 2 (2.9%), dimness of vision in one, and watering from eyes in one patient. One patient complained of redness and mucopurulent discharge from the eyes [Table 2].
Table 2: The chief presenting complaints of the respondents (n=105) (multiple responses allowed)

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The SPO2 ranges from 35 to 100 with a mean (SD) of 87.4 (12.3). Systolic blood pressure (SBP) ranges from 90 to 180 with a mean (SD) SBP of 130.4 (16.6) mmHg. Diastolic blood pressure (DBP) ranges from 47 to 106 with a mean (SD) DBP of 81.3 (11.4) mmHg. Random blood sugar (RBS) ranges from 60 to 500 with a mean (SD) RBS of 168.2 (88.7) mg/dl.

Out of the 105 patients, 23 (21.9%) were vaccinated with the first dose, 12 (11.4%) were fully vaccinated with two doses of vaccine, whereas 70 (66.7%) patients were not vaccinated for COVID-19. In chest X-ray, bilateral moderate consolidation was found in 59 (56.2%) of patients, bilateral mild consolidation in 34 (32.4%), unilateral consolidation in 11 (10.5%), and normal chest X-ray in one patient [Table 3].
Table 3: Vaccination status and clinical parameters of the respondents (n=105)

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Ocular manifestations were present in 12 (11.4%) of postCOVID19 patients, [Table 4] whereas 93 (88.6%) did not show any eye manifestations. Dry eye was the most common manifestation found in 3 (2.8%) of post-COVID-19 patients and two patients each (1.9%) had refractive error, allergic conjunctivitis, and subconjunctival hemorrhage [Figure 1] and [Figure 2]. One patient was found to be suffering from mucopurulent conjunctivitis with redness and mucopurulent discharge from the eyes. Retinal hemorrhage in one patient was due to branch retinal vein occlusion (BRVO) of the right eye [Figure 3]. Another patient was found to be having exposure keratopathy with whole cornea stained with fluorescein [Figure 4]. Before the event of COVID-19 infection, one patient was emmetropic for far and using presbyopia correction of + 1.75DS. After recovering from the disease, a refractive error of − 0.50DS was found in both eyes with presbyopic correction same as before. Another patient was found to be having a refractive error of − 0.25DCyl 90° in both eyes with + 2.50DS presbyopic correction after recovery from COVID-19.
Figure 1: Subconjunctival hemorrhage 1

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Figure 2: Subconjunctival hemorrhage 2

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Figure 3: Branch retinal vein obstruction

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Figure 4: Exposure keratopathy

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Table 4: Ocular manifestations of the respondents (n=105)

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  Discussion Top

This is the first study on ocular manifestations of post-COVID-19 patients in a tertiary care center in the Northeastern part of India. Our study found 12 (11.4%) of post-COVID-19 patients with ocular manifestations. In a systemic review and meta-analysis on ocular manifestations of COVID-19 by Nasiri et al., the prevalence of ocular manifestations in COVID-19 was estimated to be 11.03%.[22]

Tohamy et al. found in a study in Egypt on post-COVID-19 patients that 5% of patients had retinal vein occlusion, 2% had anterior ischemic optic neuropathy, 3% had uveitis, and 2% had central serous retinopathy.[23] Our study found 1 (1%) case of retinal hemorrhage due to BRVO. Before COVID-19, the incidence of retinal vein occlusion was 1.02 per 1000 patients.[24]

Johansson et al. found in a study in Sweden a total of 31% of patients with rehabilitation needs after COVID-19-reported vision-related symptoms which were reading-related issues (73.8%), blurry vision (69.0%), and light sensitivity (66.7%).[25] Gangaputra and Patel found 11.1% of nonhospitalized COVID-19 patients with blurred vision.[26] Costa et al. did a study nested within a cohort study named Recovida and found myopia <–0.50D in 31.7% and hyperopia >+0.50D in 41.2% of patients.[27] Two patients (1.9%) were found to be having vision-related problems in the form of blurred vision for both far and near in our study. Costa et al. found dry eye disease in 38.7% of patients.[27] Dry eye was found in 3 (2.8%) of patients in our study.

Sindhuja et al. in a study on the clinical profile of conjunctivitis in mild COVID-19 patients found conjunctival congestion in 6.29% of patients.[28] Navel et al. reported a case of hemorrhagic conjunctivitis with pseudomembranous formation related to SARS-COV-2.[29] Our study found 5 (4.8%) patients with red eyes out of which 2 (1.8%) were suffering from allergic conjunctivitis and 2 (1.8%) from subconjunctival hemorrhage and one from mucopurulent conjunctivitis.

Studies on eye care in intensive care units have shown 20% –40% of patients in intensive care unit develop exposure keratopathy.[30],[31] Feng et al. found one case of exposure keratopathy in a study on hospitalized COVID-19 patients in the United States.[32] One patient in our study showed exposure keratopathy and may be due to prolonged stay in intensive care receiving assisted ventilation.

Our study has its limitations as the study is restricted to only one tertiary care center where serious post-COVID cases were admitted. Some presenting symptoms and signs may have been missed as the patients may have failed to complain about the less significant ocular problems while focusing on the severe respiratory or other comorbidities. Regardless, these study findings may shed some light on post-COVID-19 ocular manifestations in our part of the world.

  Conclusion Top

As the pandemic continues, it is imperative for physicians, ophthalmologists, and general public to understand the manifestations of COVID-19 and post-COVID-19. In this study, 11.4% of hospitalized post-COVID-19 patients have ocular manifestations. Post-COVID-19 syndrome could affect the eyes thus necessitating meticulous follow-up of patients who recovered from COVID-19.

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Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2], [Table 3], [Table 4]


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