Monocular visual loss as the presenting symptom of COVID-19 infection

Central retinal artery occlusion in a young child affected by COVID-19: a first case report

BACKGROUND

Central retinal artery occlusion (CRAO) is an ophthalmic emergency, and its etiology is generally ascribed to vessel occlusion by a thrombus or embolus, eventually due to a hypercoagulable state. CRAO occurrence is described even in the pediatric population, but its incidence is very rare. SARS-CoV-2 infection has a multitude of presentations, and almost any organ may be involved including the ocular district. Cases of CRAO in patients affected by COVID-19 are reported in the literature in the adult population, but not in the pediatric one.

CASE PRESENTATION

We describe the case of a six-year-old otherwise healthy girl, who presented a sudden and complete bilateral vision loss after a one-day fever. All the clinical, ophthalmological, laboratory and instrumental investigations led to the diagnosis of a right CRAO and the suspicion of a contralateral posterior optic nerve affection. These manifestations could not be ascribed to any etiological condition apart from the documented ongoing mild SARS-CoV-2 infection. Treatment with anticoagulants and steroids was tried but the visual outcome was poor during the one-month hospitalization and at the last follow-up.

CONCLUSIONS

To the best of our knowledge, this is the first report of CRAO in the course of SARS-CoV-2 infection in the pediatric age. In our review of the literature, we found few cases of CRAO in adults with COVID-19; we highlighted differences in anamnestic, clinical, and interventional aspects and therefore we tried to summarize the state of the art on this topic to facilitate further studies. Even if rare, the prognosis of CRAO is poor and the thrombolytic treatment could be effective only if rapidly administered, so the disease suspicion should be high in a patient with sudden vision loss, also in pediatric age.

The spectrum of COVID-19-associated chorioretinal vasculopathy

Purpose

Although conjunctivitis represents the most common ocular manifestation of COVID-19 infection, sight-threatening retinal involvement has been reported. Herein, we report and characterize with multimodal retinal imaging 5 cases of acute vision loss secondary to presumed chorioretinal vasculopathy temporally associated with COVID-19 infection with varying severity, visual morbidity, and treatment response, and review the available literature on the association between COVID-19 infection and retinal microvascular changes.

Design

Observational case series and literature review.

Methods

Multicenter case series of 5 patients who presented to academic centers and private offices with acute vision loss temporally associated with COVID-19 infection. A review of the literature was conducted using online databases.

Results

10 eyes of 5 patients, 3 men and 2 women, with a mean age of 30.8 years (median 33, range 16-44) were described. All patients had a recently preceding episode of COVID-19, with symptomatology ranging from mild infection to life-threatening encephalopathy. Treatment for their retinal disease included topical, oral, intravitreal, and intravenous steroids, steroid-sparing immunosuppression, retinal photocoagulation, antivirals, and antiplatelet and anticoagulant agents. Treatment response and visual recovery ranged from complete recovery of baseline acuity to permanent vision loss and need for chronic immunosuppression.

Conclusions and Importance

Clinicians should be mindful of the potential for vision-threatening retinal involvement after COVID-19 infection. If found, treatment with both anti-inflammatory therapy and anticoagulation should be considered, in addition to close monitoring, as some patients with this spectrum of disease may require chronic immune suppression and/or anti-VEGF therapy.

Retinal vascular occlusions in COVID-19 infection and vaccination: a literature review

PURPOSE

Abnormal hypercoagulability and increased thromboembolic risk are common in patients with coronavirus disease (COVID-19). COVID-19 has been suggested to cause retinal vascular damage, with several studies on COVID-19 patients with retinal vascular occlusions. We reviewed and investigated studies on retinal vascular occlusions in patients diagnosed with COVID-19 and in those vaccinated for COVID-19.

METHODS

Studies that reported retinal vascular occlusion in COVID-19 patients or in vaccinated people were identified using the terms "retinal occlusion," together with "severe acute respiratory syndrome coronavirus 2", "SARS-CoV-2," "COVID-19," "coronavirus," and "vaccine," through systematic searches of PubMed and Google Scholar databases until January 7, 2022.

RESULTS

Thirteen cases of retinal artery occlusion (RAO) and 14 cases of retinal vein occlusion (RVO) were identified among patients diagnosed with COVID-19. Half of the patients with RAO or RVO revealed no systemic disorders except current or past COVID-19, and ocular symptoms were the initial presentation in five cases. Among patients with RAO, most presented with central RAO at 1-14 days of COVID-19 diagnosis, with abnormal coagulation and inflammatory markers. Among those with RVO, two-thirds presented with central RVO and one-third with RVO. Eleven cases with acute macular neuroretinopathy (AMN) and/or paracentral acute middle maculopathy (PAMM) were reported among patients with COVID-19, presenting scotoma resolved spontaneously in most cases. Among the 26 cases vaccinated with either mRNA or adenoviral vector vaccines for COVID-19 and presenting retinal vascular occlusions, there were more RVO cases than RAO cases, and ocular symptoms mostly occurred within 3 weeks after vaccination. One case presented bilateral AMN and PAMM after COVID-19 vaccination.

CONCLUSION

Retinal vascular occlusions might be a manifestation of COVID-19, although rare, especially in patients at risk of systemic hypercoagulability and thromboembolism. For COVID-19 vaccines, the causal relationship is controversial because there are few case reports of retinal vascular occlusions after COVID-19 vaccination.

Isen D, Tavakoli M. Neuro-ophthalmic Manifestations of Coronavirus Disease 2019 and Its Vaccination: A Narrative Review

Coronavirus disease 2019 (COVID-19) is a current pandemic caused by SARS-CoV-2 that has vastly affected the whole world. Although respiratory disease is the most common manifestation of COVID-19, the virus can affect multiple organs. Neurotropic aspects of the virus are increasingly unfolding, in so far as some respiratory failures are attributed to brainstem involvement. The neuro-ophthalmic manifestations of COVID-19 and the neuro-ophthalmic side effects of vaccination were reviewed. The major findings are that the SARS-CoV-2 infection commonly causes headaches and ocular pain. It can affect the afferent and efferent visual pathways by ischemic or inflammatory mechanisms. Optic nerve may be the origin of transient or permanent visual loss from papillophlebitis, idiopathic intracranial hypertension, or optic neuritis. Cerebrovascular strokes are not uncommon and may lead to cortical visual impairment or optic nerve infarction. SARS-CoV-2 may affect the pupillomotor pathways, resulting in tonic pupil (Adie's syndrome) or Horner's syndrome. Cranial neuropathies including third, fourth, sixth, and seventh nerve palsies have all been reported. Rhino-orbital mucormycosis superinfections in COVID-19 patients receiving steroids or other immunosuppressive therapies may result in unilateral or bilateral visual loss and ophthalmoplegia. Autoimmune conditions such as Guillain-Barré, Miller-Fisher syndrome, and ocular myasthenia have been reported.

[Ophthalmic manifestations of COVID-19]

In March 2020 the World Health Organization (WHO) declared a pandemic of the novel coronavirus infection (COVID-19) caused by the SARS-CoV-2 respiratory virus. The high spread rate of the virus and the severity of the course of the disease are of great clinical and epidemiological significance, making it relevant for ophthalmologists to study the mechanisms of how SARS-CoV-2 infects ocular structures, as well as possible clinical manifestations of the infection in the organ of vision. This review contains analysis, systematization, and generalization of epidemiological and clinical data on SARS-CoV-2 ocular lesions and was carried out with the data found in scientific abstract databases. The article presents main clinical ophthalmic manifestations of COVID-19, lists the utilized schemes of etiotropic and symptomatic therapy, recommended preventive measures, and considers the possible ophthalmic complications after vaccination against COVID-19.

[German S1 Guideline Long-/Post-COVID]

The German Society of Pneumology initiated 2021 the AWMF S1 guideline Long COVID/Post-COVID. In a broad interdisciplinary approach, this S1 guideline was designed based on the current state of knowledge.The clinical recommendations describe current Long COVID/Post-COVID symptoms, diagnostic approaches, and therapies.In addition to the general and consensus introduction, a subject-specific approach was taken to summarize the current state of knowledge.The guideline has an explicit practical claim and will be developed and adapted by the author team based on the current increase in knowledge.

“Vision Loss” and COVID-19 Infection: A Systematic Review and Meta-Analysis

Background: Visual impairment in terms of reduced visual acuity and “visual loss” has been reported as an atypical symptom in patients with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. This systematic review and meta-analysis aims to assess the cumulative incidence of “visual loss” during coronavirus disease 2019 (COVID-19) and review the current evidence regarding “visual loss” caused by SARS-CoV-2 infection. Methods: We performed a systematic review and meta-analysis of studies following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We systematically searched the PubMed, Embase, and Scopus databases for relevant studies published that clearly described “vision loss” and SARS-CoV-2 infection. All studies reporting concomitant “vision loss” and laboratory-confirmed SARS-CoV-2 infection were included. Meta-analyses were conducted using the measurement of risk and a 95% confidence interval for each study. Results: Our search identified 1143 manuscripts published in the English language. After study screening, twenty-nine articles were selected: two cross-sectional studies, twenty-four case reports, and three case series. A random-effect meta-analysis demonstrated that the pooled “visual loss” cumulative incidence in COVID-19 patients was 0.16 (95% CI 0.12–0.21). The quality rating of the cross-sectional studies averaged four out of the maximum score on the Newcastle–Ottawa scale. Conclusions: COVID-19 infection might cause “visual loss”. Even if the current evidence is limited, ophthalmological assessment should be promptly provided to all patients experiencing visual impairment symptoms during SARS-CoV-2 infection.

Retrospective diagnosis of COVID-19 following the detection of central retinal artery occlusion

Thromboembolic complications are being increasingly reported in patients with COVID-19 due to the associated hypercoagulability and are an important cause for morbidity and mortality. Retinal vascular occlusions especially arterial occlusions are one of the gravest ocular complications reported. This complication may occur in severe cases with cytokine storm or even in mild or asymptomatic patients and presentation can be anytime from few days to weeks after the onset of symptoms. Ophthalmologists should be aware of this new etiology when dealing with patients having features of retinal vascular occlusions and should investigate for the same in this pandemic situation. Although reverse transcriptase polymerase chain reaction is the diagnostic test for COVID-19, serological assays have a role in patients with delayed presentation. We describe the clinical features and multimodal imaging findings in a patient who presented with features of central retinal artery occlusion with cilioretinal artery sparing wherein his ophthalmic condition led to the diagnosis of previously undetected COVID-19 through serology. To the best of our knowledge, this is the first documentation of a case of isolated central retinal artery occlusion leading to a retrospective diagnosis of COVID-19.

Hemi- and Central Retinal Vein Occlusion Associated with COVID-19 Infection in Young Patients without Known Risk Factors

PURPOSE

Venous thromboembolic complications have been reported in association with coronavirus disease 2019 (COVID-19) infection. We raised awareness regarding a potential temporal association between COVID-19 infection and retinal vein occlusion (RVO).

DESIGN

Multicenter, retrospective, nonconsecutive case series.

SUBJECTS

Patients presenting with hemi-RVO (HRVO) or central RVO (CRVO) between March 2020 and March 2021, with confirmed COVID-19 infection, were included. The exclusion criteria were as follows: age >50 years, hypertension, diabetes, glaucoma, obesity, underlying hypercoagulable states, and those requiring intubation during hospitalization.

METHODS

This was a multicenter, retrospective, nonconsecutive case series including patients presenting with hemi-RVO (HRVO) or central RVO (CRVO) between March 2020 and March 2021, with confirmed COVID-19 infection. The exclusion criteria were as follows: age >50 years, hypertension, diabetes, glaucoma, obesity, underlying hypercoagulable states, and those requiring intubation during hospitalization.

MAIN OUTCOME MEASURES

Ophthalmic findings, including presenting and final visual acuity (VA), imaging findings, and clinical course.

RESULTS

Twelve eyes of 12 patients with CRVO (9 of 12) or HRVO (3 of 12) after COVID-19 infection were included. The median age was 32 years (range, 18-50 years). Three patients were hospitalized, but none were intubated. The median time from COVID-19 diagnosis to ophthalmic symptoms was 6.9 weeks. The presenting VA ranged from 20/20 to counting fingers, with over half (7 of 12) having a VA of ≥20/40. OCT revealed macular edema in 42% of the eyes; of these, 80% (4 of 5) were treated with anti-VEGF injections. Ninety-two percent (11 of 12) had partial or complete resolution of ocular findings at final follow-up. Four eyes (33%) had retinal thinning, as determined using OCT, by the end of the study interval. The final VA ranged from 20/20 to 20/60, with 11 of the 12 (92%) eyes achieving a VA of ≥20/40 at a median final follow-up period of 13 weeks (range, 4-52 weeks).

CONCLUSIONS

Although we acknowledge the high seroprevalence of COVID-19 and that a causal relationship cannot be established, we reported this series to raise awareness regarding the potential risk of retinal vascular events due to a heightened thromboinflammatory state associated with COVID-19 infection.

MYTHS AND TRUTHS OF THE ASSOCIATION OF RETINAL VASCULAR OCCLUSION WITH COVID-19

PURPOSE

To critically review data published in the recent past to scrutinize a causal relationship between retinal vascular occlusion and COVID-19.

METHOD

A comprehensive literature search was performed on Pubmed with the key words retinal vascular occlusion, retinal vein occlusion, retinal artery occlusion, and COVID-19.

RESULTS

A total of 17 case reports were published during this period, and 10 were on retinal vein occlusion and 7 on retinal artery occlusion. Most of the published reports lacked convincing evidences in one or the other aspects, such as insufficient laboratory workup or presence of multiple confounding risk factors.

CONCLUSION

In this index article, strength of the data is insufficient to establish a definitive cause-and-effect relationship of retinal vascular occlusive disorders with COVID-19. Hence, clinicians can continue to manage these cases according to the standard guidelines until there are more robust evidences to support this association to alter the diagnostic and treatment modalities.

Neurological consequences of COVID-19 and brain related pathogenic mechanisms: A new challenge for neuroscience

Due to the infection by the SARS-CoV-2 virus (COVID-19) there were also reported neurological symptoms, being the most frequent and best cited those that affect the cerebrovascular, sensorial, cognitive and motor functions, together with the neurological diffuse symptoms as for examples headache or dizziness. Besides, some of them behave high risk of mortality. Consequently, it is crucial to elucidate the mechanisms of action in brain of SARS-CoV-2 virus in order to create new therapeutic targets to fight against this new disease. Since now the mechanisms of arrival to the brain seems to be related with the following processes: blood brain barrier (BBB) disruption together with nervous or axonal transport of the virus by the trigeminal nerve, the vagus nerve, or the brain-gut-axis. Being two the mechanisms of brain affectation most cited: a direct affectation of the virus in the brain through neuroinvasion and an indirect mechanism of action due to the effects of the systemic infection. Both processes include the triggering of inflammation, hypoxia and the increased likelihood of secondary infections. This topic supposes a major novel challenge for neuroscience. Therefore, the aim of this review is to provide summarized information about the neurological symptomatology and the brain pathogenic mechanisms involved and reported in COVID-19.

[Ophthalmic manifestations in COVID-19-associated multiple mononeuropathy of the cranial nerves (clinical observation)]

Clinical manifestations of the new coronavirus infection can vary greatly and affect different organs and systems. Despite the lack of convincing data on the possible direct damage to the structures of the eyeball by the SARS-CoV-2 virus, indirect involvement of the organ of vision both in the acute period of the disease, during the period of convalescence, and as a part of the post-COVID syndrome is common in clinical practice. The condition of the ocular surface is not given much attention during the treatment of the main disease, especially in severe cases, which can lead to serious complications and visual acuity loss after recovery. Timely measures can prevent the loss of visual acuity. This article presents a description and discusses a rare case of multiple neuropathy of the cranial nerves associated with COVID-19, with bilateral involvement of the olfactory (I), trigeminal (V), facial (VII) and sublingual (XII) nerves, as well as the right optic nerve (II), which required staged rehabilitation.

COVID-19-associated mixed cilioretinal artery occlusion and central venous occlusion in a fit and healthy young patient

Retinal artery occlusion is an unusual phenomenon in younger patients without background of diseases leading to hypercoagulable states. COVID-19 infection is increasingly recognised as being associated with thrombotic conditions. We present a case of a young female who is otherwise fit and well apart from recent COVID-19 infection, who presented with a mixed cilioretinal artery and venous occlusion.

[Changes in ocular hemodynamics in patients recovered from COVID-19]

PURPOSE

To evaluate the severity of hemodynamic changes in the ocular vessels of patients recovered from COVID-19.

MATERIAL AND METHODS

The study included 44 patients (88 eyes) aged 28-60 years, among them 24 (54.5%) women and 20 (45.4%) men, with SARS-CoV-2 infection confirmed by PCR no more than 2 months prior to enrollment and with no ophthalmological complaints within 2 months before the disease, as well as 20 healthy volunteers (40 eyes). At the time of the study all patients had a negative PCR result for SARS-CoV-2. The patients were divided into 2 groups. The first group comprised 24 patients who did not take any anticoagulants during the treatment. The second group consisted of 20 patients who received anticoagulants (Rivaroxaban (Xarelto)) at a dosage of 10 mg per day for 1-1.5 months. The maximum systolic (Vs), end-diastolic (Vd) blood flow velocity, as well as resistance index (RI) in the ophthalmic artery (OA), central retinal artery (CRA) and short posterior ciliary arteries (SPCA) were measured in all study patients with the ultrasound imaging system VOLUSON E8 Expert («Kretz», USA). Additionally, the flowmetry method was used to assess the volumetric ocular blood flow (VOBF) on Ocular Blood Flow Analyzer system («Paradigm Medical Industries, Inc.», USA).

RESULTS

In the first group, a decrease in Vs and Vd was noted amid a significant increase of RI in CRA and SPCA, as well as an increase of RI in OA compared with the age-normal values (p<0.05). In the second group, a decrease in Vs and Vd was noted amid a significant increase of RI in CRA, as well as a decrease in Vs in SPCA and an increase of RI in OA relative to the age-normal values (p<0.05). A decrease in VOBF was noted in the first group in comparison to the second group and the age norm (p<0.05).

CONCLUSION

Blood flow velocity parameters in the ocular vessels are reduced in patients recovered from COVID-19 compared to the age-normal values. There was a significant decrease in volumetric ocular blood flow parameters in COVID-19 patients who did not take any anticoagulants compared to the age-normal values. Anticoagulants intake has a positive impact on hemodynamic characteristics in the ocular vessels and volumetric ocular blood flow in patients with COVID-19.

A clinical case of central retinal artery occlusion after pneumonia caused by SARS-CoV-2 (COVID-19)

In domestic and foreign medical periodical literature, highlighting the problem of ophthalmopathology against the background of coronavirus infection, the lesion of the anterior segment of the eye is most often described. It is extremely hard to find reports about pathology of the retina, optic nerve or central parts of the visual analyzer. However, it is widely acknowledged that there is a high risk of developing coagulopathy against the background of COVID-19 infection, which leads to occlusion and thrombosis of retinal vessels, ischemic neuropathies. The problem of irreversible loss of vision due to circulatory disorders of the retinal vessels was urgent even before the wide spread of coronavirus infection due to the high prevalence of atherosclerosis, hypertension and type 1 and 2 diabetes in the population. Also, it is widely known that occlusions and thrombosis of retinal vessels can be formidable harbingers of the developing life-threatening conditions. Knowledge about the high risk of vascular ophthalmopatology against the background of a previous COVID-19 infection by the primary echelon ophthalmologists, early diagnostics and treatment of ischemic conditions of the posterior segment of the eye will reduce the frequency of irreversible vision loss due to these diseases, secondary neovascular glaucoma cases, and will also help to send patients to the multidisciplinary hospitals in a timely manner for the prevention of fatal complications of coagulopathy. The article provides a brief overview of foreign literary sources regarding the history of outbreaks of coronavirus infection in the world, as well as possible ways of damage to the organ of vision by the coronavirus. A clinical case of damage to the vascular bed of the retina in both eyes due to coagulopathy against the background of pneumonia caused by COVID-19 is presented, which is actual due to the low illumination of similarly cases.

Ocular manifestations in COVID-19 patients: A systematic review and meta-analysis

Introduction

With the accumulating evidence of ocular manifestations of the 2019 novel coronavirus disease (COVID-19), the study aimed to systematically summarize the ocular manifestations in COVID-19 patients.

Methods

The PubMed, EMBASE, Web of Science databases were searched through June 2021. Studies that provided clinical characteristics and outcomes and reported on the ocular manifestations or conjunctival swab RT-PCR tests among COVID-19 patients were included.

Results

A total of 30 studies involving 5,717 patients were identified. Ocular manifestations including conjunctival hyperemia (7.6%, 95% confidence interval [CI] 1.8–8.9%), conjunctival discharge (4.8%, 95% CI 1.8–8.9%), epiphora (6.9%, 95% CI 2.8–12.8%), and foreign body sensation (6.9%, 95% CI 2.4–13.0%) were observed. The positive rate of conjunctival swab tests was 3.9% (95% CI 0.2–6.4%). Severe cases of COVID-19 were associated with an increased risk of developing ocular complications (odds ratio [OR] = 2.77, 95% CI 1.75–4.40).

Conclusions

Despite their relatively low incidence rate in COVID-19 patients, ocular manifestations may be non-specific and present as the initial symptoms of infection. The presence of SARS-CoV-2 in the conjunctival swabs implicates the eye as a potential source of infection. Early diagnosis and proper eye protection would help prevent viral transmission.

Acute monocular vision loss as presenting symptom of delayed stroke from internal carotid occlusion in COVID-19

Covid-19 infection has been declared a pandemic by the World Health Organization. We present a unique case of a middle-aged gentleman, who recovered from asymptomatic Covid-19 infection and presented again with delayed stroke. He had vision loss secondary to internal carotid artery occlusion in the absence of neurological symptoms. To the best of our knowledge, this is the first case that describes cerebrovascular stroke due to delayed large vessel occlusion secondary to Covid-19 infection presenting as monocular vision loss.