Acta Ophthalmologica 2020 Letter to the Editor Episcleritis as an ocular manifestation in a patient with COVID-19 Carlos Mendez Mangana,1,2 Anton Barraquer Kargacin1,2 and Rafael I. Barraquer1,2 1 Centro de Oftalmologıa Barraquer, Fig. 1. Sectoral conjunctival hyperaemic inflammation on the inferonasal conjunctiva in the Barcelona, Spain; 2Institut Universitari patient left eye. Barraquer, Universitat Autonoma de Barcelona, Barcelona, Spain centre, presented cough and myalgia and Chikungunya have shown to doi: 10.1111/aos.14484 without fever. On the next day, symp- develop episcleritis though to a lesser toms disappeared but were followed by degree than other ocular symptoms, anosmia and ageusia. At this moment, additionally, studies on hepatitis C nasopharyngeal PCR AbbottÒ virus showed episcleral inflammation Editor, (Abbott Laboratories, Abbott Park, could possibly be explained by the IL, USA) test is carried out with a induction of secondary vasculitis caus- T he aim of this report is to present the first case of episcleritis in a COVID-19 positive patient. positive result for COVID-19 infection. There was no relevant previous patho- ing cryoglobulinaemia and/or circulat- ing immune complexes containing In December 2019, an outbreak of a logical history of ocular complications. antibodies of the virus (Gill et al. 2016). coronavirus disease (COVID-19) Seven days after onset, ageusia and This case illustrates episcleritis as a emerged in Wuhan, China, and it has anosmia resolved, no other general signs possible ocular complication of spread quickly over the world. This or symptoms appeared except the ocu- COVID-19. To our knowledge, this is disease is caused by the new severe lar symptoms referred below. The the first report to determine episcleritis acute respiratory syndrome coron- patient consulted our Centre (Centro in a patient with COVID-19. Given the avirus 2 (SARS-CoV-2). de Oftalmologıa Barraquer, Barcelona, relationship between immune disorders Coronavirus disease (COVID-19) is Spain) referring red eye, foreign-body that induce vascular inflammation in a highly contagious disease, its pro- sensation, epiphora and photophobia episcleritis and the high-rate incidence gression can lead to acute respiratory without impaired visual acuity. Patient of thrombotic complications (31%) distress syndrome and even death. The presented a slightly elevated epibulbar reported in intensive care unit patients majority of cases are mild with most area with hyperaemia at the inferotem- with COVID-19, one pathophysiologi- common symptoms being fever, cough, poral sector without fluorescein defect cal theory that could explain the rela- fatigue and dyspnoea. Severe infections (Fig. 1). The patient was diagnosed tionship between COVID-19 and can rapidly affect the pulmonary sys- with nodular episcleritis. Treated with episcleritis may include immuno-vascu- tem, are more prone to heart injury and artificial tears on demand and fluo- lar factors and/or coagulation disor- secondary infection. There is some rometholone five times a day for 3 days, ders (Klok et al. 2020). evidence of neurological manifesta- tapered during the following weeks, Further studies on COVID-19 are tions, arrhythmia and impaired renal signs and symptoms resolved on the needed, specifically in relationship with function (Wu & McGoogan 2020). sixth day after the episcleritis onset. ocular tissues to facilitate a better Other reported symptoms are ageusia Eighteen days after the onset of myalgia understanding of its pathogenicity in and anosmia, research is being done to and cough (3 days after the resolution the eyes. encompass the broad clinical spectrum of ocular episcleritis), a second of the virus (Russell et al. 2020). nasopharyngeal PCR AbbotÒ test was The coronavirus family has previ- carried out with a negative result for COVID-19 infection. References ously been associated with conjunctivi- tis in humans just as the recent novel We recorded the ocular complica- Gill GH, Manch R & Gish R (2016): Hepatitis coronavirus, but not with episcleritis. tions of a patient with confirmed C virus as a systemic disease: reaching However, ocular manifestations of COVID-19 infection. The clinical pre- beyond the liver. Hepatol Int 10: 415–423. sentation of the case met the criteria for Klok FA, Kruip MJHA, van der Meer NJM SARS-CoV-2 have not been widely et al. (2020): Incidence of thrombotic com- reported (Zhang et al. 2020). We pre- acute nodular episcleritis, and it is plications in critically ill ICU patients with sent a case of episcleritis in a young possible that fluorometholone helped COVID-19. Thromb Res https://doi.org/10. woman diagnosed with COVID-19. treat the symptoms and resolve signs. 1016/j.thromres.2020.04.013 A 31-year-old woman, a human Other viruses pertaining to different Russell B, Moss C, Rigg A, Hopkins C, Papa S resources worker from a healthcare viral groups like Herpes zoster, Ebola & Van Hemelrijck M (2020): Anosmia and 1 Acta Ophthalmologica 2020 ageusia are emerging as symptoms in Zhang X, Chen X, Chen L et al. (2020): The Centro de Oftalmologıa Barraquer patients with COVID-19: what does the evidence of SARS-CoV-2 infection on ocu- Calle muntaner 314 current evidence say? Ecancermedicalscience lar surface. Ocul Surf 18: 360–362. Barcelona 08021 https://doi.org/10.3332/ecancer.2020.ed98 Spain Wu Z & McGoogan JM (2020): Characteris- Tel:+34 696897136 tics of and important lessons from the Fax: +34 936025337 coronavirus disease 2019 (COVID-19) out- Correspondence: Email: cmendez@uic.es break in China. JAMA 323: 1239. Carlos Mendez Mangana, MD 2