To the Editor:
The severe acute respiratory syndrome coronavirus 2 pandemic continues to pose a threat worldwide. Although children typically experience a mild course of coronavirus disease 2019 (COVID-19), severe multisystem inflammatory syndrome in children (MIS-C) is associated with the disease.1 The MIS-C pathophysiology is unclear, but possible mechanisms include antibody or T-cell recognition of self-antigens resulting in autoantibodies, antibody or T-cell recognition of viral antigens expressed on infected cells, formation of immune complexes that activate inflammation and viral superantigen sequences that activate host immune cells.2 Gastrointestinal, cardiovascular, hematologic, mucocutaneous and respiratory symptoms are common in patients with MIS-C,3 but these patients may also develop conjunctivitis in their eyes.4 Ocular manifestations other than conjunctivitis associated with MIS-C have not been identified. Herein, we present the ocular findings of 2 patients diagnosed with MIS-C.
An 8-year-old male presented with floaters in his right eye. His past history was unremarkable. Despite having no previous symptoms, an ELISA-based IgG antibody test returned a positive result for COVID-19. His best corrected visual acuity was 10/10 in both eyes, and no pathologic manifestations were noted on biomicroscopic examination. A fundus examination revealed a splinter-retinal hemorrhage around the optic nerve of the right eye (Fig. 1A), but the left eye was clear. Optical coherence tomography (OCT) revealed several vitritis-like hyperreflective dots in the posterior vitreous of the right eye (Fig. 1B). Three weeks later, the floaters had disappeared, the splinter-retinal hemorrhage regressed (Fig. 1C) and the dots were reduced (Fig. 1D).
A 10-year-old female presented with conjunctival hyperemia and a periorbital rash in both eyes. Her past history was unremarkable, but she tested positive 1 month previously on a 2019-nCoV real-time PCR test using a swab sample taken from the nasal and oral regions. Her best corrected visual acuity was 10/10 in both eyes. A biomicroscopic examination revealed nonpurulent conjunctivitis in both eyes, and a fundus examination revealed dilatation and minimal tortuous increase in the retinal arteries and veins of both eyes (Fig. 2A). OCT imaging revealed several vitritis-like hyperreflective spots in the posterior vitreous of both eyes (Fig. 2B). Three days later, the conjunctivitis had regressed spontaneously. At the 2-week follow-up, the dilatation and tortuosity in the retinal arteries and veins had decreased in both eyes (Fig. 2C), but there was only minimal regression of the hyperreflective dots (Fig. 2D).
MIS-C may cause conjunctivitis in the eye, but the posterior segment findings of the eye are unknown.4 Recently, reports have emerged regarding the involvement of the posterior segment of the eye in adult with COVID-19.5,6 Subtle cotton wool spots and retinal hemorrhages have also been detected on color fundus photography.7 Zago Filho et al8 detected hyperreflective pinpoints at the posterior vitreous hyaloid level on OCT in a 57-year-old patient with COVID-19 and demonstrated that COVID-19 can cause vitritis. Invernizzi et al5 evaluated the retinal arteries and veins around the optic disc in adults with COVID-19 and found retinal dilated veins and tortuous vessels; observed that both the retinal artery and vein diameters were larger in patients with COVID-19 than in the controls.
To the best of our knowledge, this is the first report of ocular findings of associated with MIS-C. While no pathologic manifestations were observed on the anterior segment in case 1, nonpurulent conjunctivitis and a Kawasaki disease-like periorbital rash on the eyelids were detected in case 2. There was a splinter-retinal hemorrhage observed around the optic nerve of one eye in case 1 and dilatation and minimal tortuous increase of the retinal arteries and veins in both eyes in case 2. Vitritis-like hyperreflective dots were observed in the posterior vitreous in both cases, and they persisted in case 2 despite the decrease in dilatation and tortuosity. Other ocular findings regressed in both cases.
In conclusion, various ocular findings affecting both the anterior and posterior segments of the eye may develop in children with MIS-C, and their long-term effects are unknown. Therefore, future studies are required.
1. Dufort EM, Koumans EH, Chow EJ, et al.; New York State and Centers for Disease Control and Prevention Multisystem Inflammatory Syndrome in Children Investigation Team. Multisystem inflammatory syndrome in children in New York State. N Engl J Med. 2020;383:347–358.
2. Jiang L, Tang K, Levin M, et al. COVID-19 and multisystem inflammatory syndrome in children and adolescents. Lancet Infect Dis. 2020;20:e276–e288.
3. Feldstein LR, Rose EB, Horwitz SM, et al.; Overcoming COVID-19 Investigators; CDC COVID-19 Response Team. Multisystem inflammatory syndrome in U.S. children and adolescents. N Engl J Med. 2020;383:334–346.
4. Chiotos K, Bassiri H, Behrens EM, et al. Multisystem inflammatory syndrome in children during the coronavirus 2019 pandemic: a case series. J Pediatric Infect Dis Soc. 2020;9:393–398.
5. Invernizzi A, Torre A, Parrulli S, et al. Retinal findings in patients with COVID-19: results from the SERPICO-19 study. EClinicalMedicine. 2020;27:100550.
6. Pereira LA, Soares LCM, Nascimento PA, et al. Retinal findings in hospitalised patients with severe COVID-19 [published online ahead of print October 16, 2020]. Br J Ophthalmol. doi: 10.1136/bjophthalmol-2020-317576.
7. Marinho PM, Marcos AAA, Romano AC, et al. Retinal findings in patients with COVID-19. Lancet. 2020;395:1610.
8. Zago Filho LA, Lima LH, Melo GB, et al. Vitritis and outer retinal abnormalities in a patient with COVID-19. Ocul Immunol Inflamm. 2020;28:1298–1300.