Acute Lagophthalmos due to Bell’s Palsy could be a Sign of COVID-19

ABSTRACT

We sought to investigate whether lagophthalmos was associated with coronavirus infection (COVID-19). Patients diagnosed with lagophthalmos in 2019 were included in group one (n = 9), while those diagnosed with lagophthalmos in 2020 were included in group two (n = 33). With the onset of COVID-19, we observed that the number of patients seen with lagophthalmia increased compared with the same period from the previous year. To confirm this, reverse transcriptase-polymerase chain reaction for severe acute respiratory syndrome coronavirus 2 test results were followed in patients with suspicious findings, after which blood test results were compared. The reported lagophthalmos cases increased by 367% in 2020 compared with 2019. Additionally, the mean white blood cell, lymphocyte and platelet counts of patients in group two were all significantly decreased compared with group one. Lagophthalmos due to Bell’s palsy could be a sign of COVID-19.

Introduction

Coronavirus infection due to COVID-19 was first recorded in China in December 2019 and caused a pandemic in the first quarter of 2020. The COVID-19 pathogen is a member of the Coronaviridae family, and a new coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) strain.¹ Beta coronaviruses, including the SARS-CoV-2 group, cause more mortality than the alphacoronaviruses.² It has also been reported from the beginning of the disease that patients presented with complaints, such as fever, cough, fatigue, myalgia, sputum production, dyspnoea, chest tightness diarrhoea, headache, anorexia, chest pain, sore throat, dizziness, palpitations, vomiting, and anosmia.^3–5 However, to our knowledge, there are currently no reports in literature describing a relationship between COVID-19 infection and lagophthalmos due to peripheral facial nerve palsy.

Lagophthalmos is a condition associated with the inability to close the eyelids effectively.⁶ Defective closure of the eyelids can cause excessive evaporation of the tear film, as well as corneal exposure, thus, leading to keratitis and loss of the cornea and ultimately the eye. The main cause of lagophthalmos is facial nerve palsy. We sought to investigate whether lagophthalmos was associated with COVID-19 infection by comparing patients diagnosed with lagophthalmos in 2019 and those in 2020, during the COVID-19 pandemic.

Methods

This study was planned retrospectively to review patients who came to the ophthalmology department with the complaint of insufficient blinking of the eyelids or a diagnosis of lagophthalmos between January 1, 2019 and June 30, 2019 (group one) and from January 1, 2020 to June 30, 2020 (group two). The study conformed to the tenets of the 1964 Helsinki Declaration and was approved by the ethics committee of the Sakarya University.

Patients came to the emergency department with complaints of inability to close the eyelids or facial asymmetry. In the emergency department cases of confirmed cerebrovascular disease were excluded, while cases of central or peripheral facial palsy were distinguished. Patients with lagophthalmos due to Bell’s palsy were then referred to the ophthalmology department.

In the ophthalmology department, patients were asked about their symptoms including anosmia. Those with suspected symptoms and signs of COVID-19 were referred to the COVID-19 service, where nasopharyngeal swabs were taken for reverse transcriptase-polymerase chain reaction (RT-PCR) testing for SARS-CoV-2.

Patients with newly diagnosed lagophthalmos due to Bell’s palsy in the first six months of 2019 and 2020 (who had nasopharyngeal swabs to test for SARS-CoV-2) were included in the study, while those with peripheral facial palsy due to trauma, tumour, or surgery were excluded. The patient’s symptoms, eyelid reports, and ocular surface findings, as well as results of blood tests and RT-PCR from nasopharyngeal swabs for SARS-CoV-2, were then reviewed and analysed.

Data were statistically analysed using the Statistical Package for Social Sciences v.25.0 (SPSS Inc., Chicago, IL, USA). Chi-Square and Mann-Whitney-U tests were used to evaluate the significant differences between the groups. The value of statistical significance was set at P < .05.

Results

The study comprised nine patients (five male and four female) in group one and 33 patients (26 male and seven female) in group two. Compared with 2019, the number of patients that presented with sudden lagophthalmos and facial asymmetry increased by 367% in 2020. The age range and mean age ± standard deviation of patients in group one were 33–53 years and 41.1 ± 6.7 years, respectively, whereas that of patients in group two was 29–65 years and 46.5 ± 9.1 years, respectively (Table 1). Seventeen patients in group two had symptoms of anosmia, of whom 13 had positive RT-PCR results for SARS-CoV-2 (Table 2). The mean white blood cell, lymphocyte and platelet counts of patients in group 2 were all significantly decreased compared with group one (Table 1).

Table 1.

Blood test results and demographic characteristics of patients

	2019 (Group One)	2020 (Group Two)	P value
Male/Total (%)	5/9 (56)	26/33 (79)	.209
Age (± Std) in years	41.1 ± 6.7	46.5 ± 9.1	.092
White blood cell count/μL (± Std)	7173 ± 1645	5265 ± 1587	<.003
Lymphocyte count/μL (± Std)	4469 ± 1753	1237 ± 513	<.001
Platelet count, ×103/μL (± Std)	344 ± 62	198 ± 60	<.001

Std = Standard deviation.

Table 2.

Distribution of reverse transcriptase polymerase chain reaction test results and the presence of anosmia symptom in group two

	Positive	Negative	Total
RT-PCR test (n) %	13 (39%)	20 (61%)	33
Anosmia symptom (n) %	17 (51%)	16 (49%)	33

RT-PCR = reverse transcriptase polymerase chain reaction.

Discussion

This study evaluated the possible relationship between COVID-19 and lagophthalmos due to Bell’s palsy. There was an unusual increase in the number of patients that attended our ophthalmology department with the clinical presentation of lagophthalmos during the pandemic compared with the same period from the previous year.

The most common cause of lagophthalmos is peripheral facial palsy, and majority of cases are due to an idiopathic, acute onset, and unilateral paralysis called Bell’s palsy.¹ Although the underlying pathophysiological mechanism of Bell’s palsy remains unknown, hypotheses indicate that viral infections or autoimmune processes contribute to the aetiology of the disease.^7,8

SARS-CoV-2 has a high affinity for angiotensin-converting enzyme 2 receptors on neurons. Therefore, various central and peripheral neurological manifestations have been associated with COVID-19.⁹ One of these manifestations, anosmia is frequently reported; thus, suggesting a distinct and early sign of the disease.¹⁰ Thus, it has been hypothesised that anosmia is due to the direct consequence of SARS-CoV-2 involvement of the olfactory nerve, in the relative absence of rhinitis and nasal congestion.¹¹ In the patients in group two, 51% had anosmia and 39% had a positive RT-PCR test for COVID-19.

Several viral infections, including herpes and Varicella zoster, have been reported as possible causative agents of peripheral facial palsy.^12–14 Peripheral nervous system involvement of coronaviruses have also been documented in animal models, with evidence that these viruses could be transported trans-neuronally from the cranial nerve endings in the nasal epithelium.¹⁵ Li et al.¹⁶ showed that peripheral inoculation of one type of coronavirus caused ganglionic infection in rats. Moreover, there are reports that peripheral nervous system disorders have also been detected in SARS-CoV-1.¹⁷ In our study, 39% of the patients with Bell’s palsy had COVID-19. It is impossible to claim that SARS-CoV-2 directly invades and damages the facial nerve without genomic evaluation of the virus in facial nerve specimens. Also, note that COVID-19 may have triggered the reactivation of latent herpes viruses, thereby indirectly causing facial nerve paralysis. Here, the leucocytes, lymphocytes, and platelet counts in the 2020 group were significantly lower than the 2019 group. Also, it has been reported that lymphopaenia and thrombocytopaenia are associated with COVID-19.¹⁸

A remarkable relationship between the possible pathogenesis of Bell’s palsy and SARS-CoV-2 is the autoimmunity hypothesis. Guillain-Barré Syndrome (GBS), an acute, immune-mediated, demyelinating peripheral nerve disease, shares several common pathophysiological features with Bell’s palsy, such as alterations in the ratios of T and B cells and similar immune responses to basic human protein.^19–23 In fact, it was proposed that a viral infection may induce an autoimmune cell-mediated reaction to the protein component of the peripheral nerve myelin that causes demyelination in both Bell’s palsy and GBS.²⁴ There were two single case reports from China and the United States of America, as well as a case series including five patients from Italy, who had COVID-19-associated GBS.^25,26 Two of the five patients had facial palsy and magnetic resonance imaging with gadolinium demonstrated the facial nerve enhancement in one patient.²⁶ Therefore, we suggest that Bell’s palsy in this study series is a mononeuritic variant of GBS. It may also be the outcome of an autoimmune response triggered by SARS-CoV-2.

In conclusion, COVID-19 is a novel and potentially fatal disease in which neurological complications may also occur. To the best of our knowledge, our study is the first to evaluate the possible relationship between lagophthalmos due to Bell’s palsy and COVID-19. Thus, clinicians should be aware that lagophthalmos due to Bell’s palsy may be a sign of COVID-19. Further case reports and studies are also needed to reveal the exact pathophysiology of the processes involved in COVID-19 complications.

Declaration of interest statement

The authors report no conflicts of interest.

Ethical Rules

Author has taken this ethical rules by Sakarya University.