Several studies have reported case studies of patients who experienced ophthalmoparesis-like symptoms including diplopia. MRI imaging points toward forms of cranial and bilateral abducens nerve palsy as possible associated-structural deficits. One patient was diagnosed with Wernicke's encephalopathy.

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In studies conducted in Wuhan, China and France, 93 patients total were found with encephalopathy. Most of these patients experienced symptoms such as dizziness, headaches, and a reduced state of consciousness.

Encephalopathy in COVID-19 Patients.

A type of encephalopathy that is associated with weakness and/or paralysis in the extraocular muscles of the eye orbit.

Ophthalmoparesis

Dinkin, M., Gao, V., Kahan, J., Bobker, S., Simonetto, M., Wechsler, P., ... & Leifer, D. (2020). COVID-19 presenting with ophthalmoparesis from cranial nerve palsy. https://pubmed.ncbi.nlm.nih.gov/32358218/

COVID-19 presenting with ophthalmoparesis from cranial nerve palsy

Pascual-Goñi, E., Fortea, J., Martínez-Domeño, A., Rabella, N., Tecame, M., Gómez-Oliva, C., ... & Gómez-Ansón. (2020). COVID-19-associated ophthalmoparesis and hypothalamic involvement. https://nn.neurology.org/content/7/5/e823

COVID-19-associated ophthalmoparesis and hypothalamic involvement

- The first presumptive case of COVID-19 associated acute necrotizing hemorrhagic (ANE)—related to intracranial cytokine storms, which result in BBB breakdown.
- 3-day history of cough, fever, and altered mental status 
- Testing for the presence of SARSCoV-2 in the CSF was unable to be performed
- Evidence of ANE:
- CT images demonstrated symmetric hypoattenuation within the bilateral medial thalami with a normal CT angiogram and CT venogram (Fig 1).
- Images from brain MRI demonstrated hemorrhagic rim enhancing lesionswithin the bilateral thalami, medial temporal lobes, and subinsular regions (Fig 2).


Case Study: COVID-19–associated Acute Hemorrhagic Necrotizing Encephalopathy: CT and MRI Features

- show brain tissue edema
- partial neuronal degeneration
- presence of SARS-CoV-2 in the CSF

Brain Autopsy Reports of CoV-19 patients in Beijing Ditan Hospital

Case Study: COVID-19-Associated Ophthalmoparesis and Cranial Nerve Palsy

When SARS-Cov2 activates cytokines (interleukin-1, interleukin-16, and TNF-alpha), it penetrates the blood-brain barrier (BBB), leading cytokines to cross the brain parenchyma. A powerful subsequent inflammatory response and the influx of blood material into the brain causes encephalopathy, as well as seizures.

Cause of Encephalopathy in COVID-19 Patients

In a study of 43 patients, one (55-year old female) was diagnosed with acute parainfectious encephalopathy with psychosis. The patient did not have a psychiatric history. A day after she was discharged after having COVID-19, her husband reported confusion, abnormal behaviour, and features of psychosis. Even though her disorientation improved, her psychosis did not. Though fluctuating, she trended towards improvement after treatments with haloperidol, followed by risperidone.

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