In Vivo confocal microscopy findings after COVID-19 infection

To evaluate clinical and in vivo confocal microscopy (IVCM) findings of a patient who developed multiple unilateral subepithelial stromal opacities following conjunctivitis that developed during a COVID-19 infection.

A 22-year-old female presented to our clinic with blurred right vision. The history revealed that she had experienced a COVID-19 infection one month ago. Redness and stinging of the right eye had started at the same time and she had been prescribed topical antibiotic drops and ointments. The redness in the right eye had decreased but blurred vision had then developed.

Slit lamp examination revealed a normal left eye. Several tiny subepithelial infiltrates without fluorescein staining of the cornea were present in the right eye. The anterior chamber, lens and fundus were bilaterally normal. IVCM revealed irregular corneal epithelial cells with bright borders in addition to scattered inflammatory cells and cell debris in the right eye. There were activated dendritic cells in the subbasal epithelial area with a significant decrease in the subbasal corneal nerve plexus. Clusters of highly reflective cells with an irregular shape were seen in the anterior corneal stroma together with foci of activated keratocytes. The corneal endothelial cell layer was normal. The left eye IVCM findings were all within normal limits. The right eye also showed decreased corneal sensitivity compared to the left.

The possible role of corneal infiltrates as a trigger for COVID-19 could be explained with an immune-mediated mechanism. SARS-CoV-2 can result in decreased corneal sensitivity through corneal nerve involvement. The clinical results of this effect need to be evaluated in larger series.