COVID-19: ocular manifestations and associations with corneal transplant rejection and uveitis reactivation

To highlight the ocular manifestations associated with COVID-19 and review the evidence surrounding proposed associations with corneal transplant rejection and uveitis reactivation.

SARS-CoV-2 has been associated with various ocular manifestations, most commonly conjunctivitis. Less frequently, more severe complications such as uveitis, retinal vascular occlusions, and neuro-ophthalmic syndromes have been reported. These manifestations are theorized to occur secondary to both direct viral invasion as well as secondary systemic inflammation and immune dysregulation. While case reports suggest a possible link between COVID-19 infection and vaccination and corneal graft rejection, large cohort studies and meta-analyses have not confirmed an association. In contrast, retrospective data suggest a slight increase in uveitis recurrence following COVID-19 infection and vaccination in patients with prior uveitis.

Ocular involvement in COVID-19 ranges from mild conjunctivitis to rare, vision-threatening inflammatory and vascular complications. While case reports have suggested temporal links between COVID-19 infection or vaccination and corneal transplant rejection or uveitis reactivation, current evidence does not support an association with graft rejection, and only a slight increase in uveitis recurrence has been observed in certain high-risk populations. With longer follow-up and prospective analyses, a clearer understanding of underlying mechanisms and risk factors may emerge to better guide ophthalmic management during and beyond the pandemic.