key: cord-0686055-qz8znmft
authors: Kirsch, Claudia F.E.
title: The Eyes Have It: Looking Carefully at the Orbits and SARS-COV-2
date: 2021-02-16
journal: Radiology
DOI: 10.1148/radiol.2021210058
sha: f37d450b697b0f906616d1f6fcf9c15c5df0832d
doc_id: 686055
cord_uid: qz8znmft

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I n p r e s s because orbital pathology can indicate central nervous system pathology (4). Orbital involvement from COVID-19 was reported in a case series from China, in up to 31.6% of patients. The ocular manifestations of COVID-19 included conjunctivitis, conjunctival hyperemia, chemosis, epiphora, and increased secretions (5) . A systematic analysis of subsequent publications highlighted the orbital implications of coronavirus involvement and transmission during the global COVID-19 pandemic (6) . In fact, in some patients, orbital conjunctivitis may be an early and only presenting finding of COVID-19 (7) . As radiologists, we are acutely aware of how vital imaging is for identifying disease manifestation. But there is a paucity of articles in the imaging literature describing the orbital radiographic manifestations of COVID-19. Only a limited number of articles and case reports present radiographic features describing orbital cellulitis chemosis, retinopathy, and optic neuritis in patients with COVID-19 (8, 9) .

Johann Wolfgang Goethe once remarked, "We only see what we know." As radiologists, we rely on our eyes to make critical findings. But disease manifestation can be "overlooked" Study," published in this issue of Radiology of vital importance (10) . It is the first article to report on radiographic MRI ocular findings in a case series of 9 patients critically ill with COVID admitted to intensive care. Using 1.5 T and 3.0 Tesla MRI, the authors retrospectively report on finding isointense T1, hyperintense FLAIR nodules on either 1.5 or 3 Tesla MRI along the posterior globe macular region in 9 patients with COVID-19 in the intensive care unit. The ocular nodular findings occurred bilaterally in 8 of 9 patients (89%) and outside of the macular I n p r e s s region in 2 patients. The nodules were most prominent and preferentially located in the papillomacular bundles of globes (10) . In this subset, 3 of 9 patients (33%) with the positive nodular lesions on MRI had a normal fundoscopy of the posterior globe, and 1 of the 9 patients also had a normal optical coherence tomography (OCT). Although the etiology of these nodular ocular findings is unknown, the authors present well-documented evidence of how viruses cause microangiopathic damage by inflaming the retina, choroid, and optic nerve. As the authors note, SARS-CoV-2 targets angiotensin-converting enzyme related carboxypeptidase (ACE2) receptors, and these receptors are highly expressed in the retina and choroid of the orbit (10).

Because ACE2 is vasoprotective to the retina via the renin-angiotensin system, if ACE2 becomes downregulated because of SARS-CoV-2, then a retinal ischemic event may occur. As discussed by the authors, additional studies using OCT also demonstrated hyper-reflective lesions along the ganglion cell level in inner plexiform layers with cotton wool exudates, most pronounced at the papillomacular bundles in both orbits (10) . It is important to remember that these imaging studies are being done on critically ill patients. Additional potential etiologies also presented by the authors include how critically ill ICU intubated patients may be placed in Valsalva, which can create increased venous pressure and result in inadequate orbital venous drainage (10) .

The authors recognize the limitations of their retrospective study. They realistically note that it was not always possible to obtain high resolution spatial dedicated ocular MRI sequences in critically ill ICU patients or obtain precise ocular conjunctival sampling for SARS-CoV-2. Nonetheless, it is critical to remember that eye problems can go unrecognized in the ICU, and clinicians need to be vigilant in first identifying if there is an orbital problem to protect the patient's vision. As the authors suggest, severe eye problems may go unnoticed when clinicians focus on life-threatening aspects of the COVID-19 disease. Ocular pathology, that may I n p r e s s otherwise go unnoticed, may be identified and appreciated by using high resolution spatial 3D T2-weighted and post-contrast fat-suppressed T1-weighted MRI, fundoscopy, and optical coherence tomography. This essential article is one of the first to report these ocular radiographic findings. Like all good articles, when first seen and now reported, others will start to "see" this finding and start reporting on it as well. To help and benefit patients, early recognition and awareness of a disease manifestation with accurate dissemination is critical, as when Dr. Li tried to warn others of the newly developing pneumonia that he saw early on as an ophthalmologist in patients with eye findings. Awareness of a new finding, the dissemination of this information, and sharing with colleagues leads to others recognizing the problem, education, research, understanding, and improved outcomes.

This important Radiology article is the first to present the MRI ocular imaging disease manifestations of COVID-19. Ocular pathology from the SARS-CoV-2 virus often signifies a more severe disease process and may be occurring with greater prevalence than currently reported and visually underappreciated on current MRI. By publishing this article, the authors will help others appreciate and recognize this critical ocular MRI finding. A true hallmark of a "landmark" article is one that recognizes and reports on a critical finding not yet reported, elucidates the findings so that others can see and find it, and helps improve outcomes for patients. This article reminds all radiologists to pay attention to the orbits on MRI, especially in patients critically ill with COVID-19 admitted to intensive care. The paper identifies where the orbital nodular macular pathology occurs and how best to appreciate it while highlighting potential disease mechanisms, enhancing our understanding of the COVID-19 disease process, and hopefully leading to improved outcomes for all affected in this pandemic.

Dr Kirsch is a Professor of Neuroradiology and Otolaryngology and the Neuroradiology Division Chief at Northwell Health Zucker Hofstra School graduating Cum Laude from Amherst College with a B.A. in Neuroscience and Fine Arts, graduated Medical School as Alpha Omega Alpha with Honors, followed by a radiology residency at University of California San Francisco, and Neuroradiology Fellowships George Washington University and Beth Israel Medical Center with Radiology Board and Neuroradiology certification. She received the American Society of Neuroimaging Oldendorf award and has received numerous research and teaching awards, as well as an international award for development of award-winning educational interactive 3-D software of head and neck anatomy. She has author or co-authored numerous peer-reviewed publications, book chapters and is a former Vice-Chair Expert Panel on Neuroimaging for American College of Radiology Appropriateness Use Criteria Committee, and American Society of Neuroradiology Collaborative Committee for Practice Parameters in Computed Tomography of the Head and Neck. She continues to serve on numerous committees including the educational, program and research committees of the American Society of Head and Neck Imaging and the Radiological Society of North America, American Society of Functional Imaging, and Association of University Radiologists, and is Past President of the Eastern Neuroradiological Society. She is an invited speaker nationally and internationally on skull base and head and neck imaging and pathology including a TEDx talk on how cancer "hitchhikes" via perineural invasion through the skull base. Her current research and publications focus on skull base and viral mediated pathology in the head and neck including work on Idiopathic Intracranial Hypertension, Human Papilloma virus (HPV), Epstein Barr Virus (EBV) and more recently SARs-CoV-2 COVID19 pathology in the head and neck, including as a co-investigator on a Foundation Government Clinical Trial assessing Phase III trials, and Primary Investigator Grant recipient, on Pseudotumor Cerebri. Administratively, she focuses on fostering a collaborative inspiring environment to encourage innovative research, and improve patient outcomes.

WHO Novel coronavirus -China

Characteristics of Ocular Findings of Patients With Coronavirus Disease

COVID-19: Ophthalmological Aspects of the SARS-CoV 2 Global Pandemic

Conjunctivitis can be the only presenting sign and symptom of COVID-19

Orbital cellulitis, sinusitis and intracranial abnormalities in two adolescents with COVID-19

Ocular manifestations of a hospitalised patient with confirmed 2019 novel coronavirus disease

Ocular MRI Findings in Patients with Severe COVID-19: A Retrospective Multicenter Observational Study