Iatrogenic Bilateral Sequential Ocular Sympathetic (Horner Syndrome) Turned Bilateral Parasympathetic Pupil Involvement Associated with Long Coronavirus-Related Dysautonomia: A Case Report

This report presents an unusual case of sequential, pharmacologically confirmed iatrogenic bilateral Horner syndrome followed by bilateral Adie's tonic pupil, highlighting the spectrum of ocular dysautonomia associated with long coronavirus disease 2019 (COVID-19). A 41-year-old woman with a history of coronavirus disease 2019 reinfection and multiple comorbidities developed pharmacologically confirmed bilateral Horner syndrome after bilateral stellate ganglion blocks. Subsequent worsening of long COVID-19 symptoms alongside systemic dysautonomia emerged, including postural orthostatic tachycardia syndrome, orthostatic hypotension, and mast cell activation syndrome. The patient then presented with bilateral, poorly reactive, enlarged pupils, and light-near dissociation. Bilateral Adie's tonic pupil was pharmacologically confirmed. Neuroimaging and laboratory workup were unremarkable. As more cases of long COVID-19 emerge, physicians should be aware that long COVID-19 can manifest with rare neuro-ophthalmic presentations, including bilateral pupillary autonomic dysfunction.