Discussion:
Acute anterior uveitis is the most common type of uveitis and is defined as inflammation of the iris (middle layer of the eyes). While idiopathic uveitis is the major type, various etiologies have been described for uveitis including autoimmune inflammatory systemic disorders (AIDS), infections, side effects of medications, eye injury, etc. [4] AIDS-causing anterior uveitis including HLA B-27 associated spondyloarthritis, Juvenile idiopathic arthritis-associated uveitis, sarcoidosis, systemic lupus erythematosus, Behcet’s syndrome and Crohn’s disease [5]. Viruses have been found to be the commonest infectious agents causing anterior uveitis. Common etiologies of viral anterior uveitis are herpes simplex virus, varicella-zoster virus, cytomegalovirus, and rubella. Human immunodeficiency virus and human T-cell lymphotropic virus type 1 are less common etiologies [6].
Here, we reported a case of bilateral anterior uveitis and optic disk edema with a positive PCR test for COVID-19 infection. She met the MIS-C diagnostic criteria of both WHO and, the Center for Disease Control and Prevention (united states) for the presence of fever, skin rashes, diarrhea, cardiac involvement, respiratory involvement, elevated ESR and CRP, and positive PCR of COVID-19. As we know MIS-C leads to multi-organ involvement, but ocular involvement is not a part of the diagnostic criteria yet [3]. Bettach et al [7] described a 54-year-old female diagnosed with bilateral anterior uveitis. She was hospitalized for multisystem inflammatory syndrome secondary to COVID-19 infection two weeks prior to the diagnosis of uveitis. At that time, she was treated with corticosteroids, vasopressors, and antibiotics. In contrast, our patient had a negative PCR test for COVID-19 from a nasopharyngeal swab but SARS‐CoV‐2 immunoglobulin G was positive showing a previous COVID-19 infection. She has successfully treated with topical dexamethasone 0.1% and cycloplegia. This previous case report confirms the concept that uveitis could be a part of multisystem inflammatory syndrome secondary to COVID-19 infection.
Based on the current knowledge of COVID-19 infection, various organs could be affected during the acute phase of COVID-19 infection. The reason is the expression of the ACE 2 receptor by different human tissues, which builds the main route for the virus to enter tissue cells. Different parts of the ocular system might be invaded through this mechanism. Conjunctivitis is the most well-recognized ocular involvement in COVID-19 infection [8]. Alcalde et al [9] investigated 17 children with COVID-19, in which conjunctivitis was the most frequently detected ocular finding (three patients). Two patients had episcleritis, one had retinitis, and one had optic neuritis. Mazzotta et al [10] reported acute anterior uveitis and acute bilateral follicular conjunctivitis in a 30-year-old female patient with a positive PCR test for COVID-19. Iriqat et al [11] reported three cases of uveitis in 19, 29, and 62-year-old males. The first one had bilateral anterior uveitis, the second one had bilateral intermediate and posterior uveitis, and the last one had right eye iridocyclitis. Rheumatologic tests returned negative for all of them. They were successfully treated with topical and systemic steroids.
We conclude that acute anterior uveitis and optic disk edema could be a manifestation of the acute phase of COVID-19 infection or occurs as a part of MIS secondary to COVID-19. Since uveitis could be an eye-threatening condition, physicians must pay attention to this less-recognized manifestation of COVID-19 infection to avoid irreversible complications.