White dot syndrome associated with SARS-CoV-2 infection

What is it about?

A 47-year-old female visited our department with complaints of bilateral photophobia and blurred vision in both her eyes. She visited our department during the pandemic period after her PCR-proven SARS-CoV-2 positivity. Her symptoms were chills and fever with a temperature of 40.0°C, associated with fatigue, sweat, and complete loss of taste. Besides basic ophthalmological examinations, ocular diagnostic testing were made to differentiate between specific white dot syndromes with suggestive features of fluorescein angiography, optical coherence tomography, and fundus autofluorescence. Laboratory tests were ordered, including immunserological and haematological ones. Eye examination revealed mild bilateral vitritis and white dots in the fundus of both eyes, including the macula explaining the blurred vision. CoVs can produce many types of ocular manifestations from anterior segment pathologies like conjunctivitis and anterior uveitis to sight-threatening conditions like retinitis and optic neuritis . CoV creates two different phases: the first is represented by the primary infection which induces a trigger of the immune system, while the second phase is probably an autoimmune disease like reaction-based pathology . The lesions presented by our patient support the hypothesis that a herpes infection can manifest after SARS-CoV-2 infection. Multiple evanescent white dot syndrome is an acute, multifocal, and rarely bilateral retinopathy. The multiple white infiltrations or foci can be seen at the level of the outer retina. We do not know the definite origin of MEWDS, but infectious and/or immune origin is suspected. The occurrence of MEWDS following hepatitis B, varicella, meningococcus infection, or vaccination suggests environmental triggers . In our case, SARS-CoV-2 could trigger the inactive herpes simplex infection that caused MEWDS. Recovery of vison in a few weeks was coincident with the return of the serum IgM values to normal. The natural course of MEWDS is excellent, and no intervention is required, but in the time of SARS-CoV-2, local steroid therapy is recommended to keep the best visual acuity . Periocular and intraocular corticosteroids are not suitable for recommendation in management of MEWDS, but in time of SARS-CoV-2 pandemic, it is recommended although there is no abundant evidence to prove whether the resolution of MEWDS is self-limiting or relays on corticosteroid.

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Why is it important?

The COVID-19 is known to affect visual system, causing ocular manifestation. The ocular system may play a role in viral transmission. The virus may shed from ocular surface secretions and tears which facilitates viral spreading. The initial viral infection may also occur on ocular surface tissues. Otherwise, the virus may spread to the respiratory system of the same individual with the ocular system acting as a conduit . The SARS-CoV-2 may also constitute the risk factor for reactivation of the herpes family viruses. After getting inside the human body, they use various mechanisms to spread. After the initial infection, herpes viruses remain in a latent state in different cells. They can be later reactivated in cases of immunodeficiency.

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