Acute Macular Neuroretinopathy Associated with Acute Influenza Virus Infection

Case report: A case of Acute Macular Neuroretinopathy secondary to Influenza A virus during Long COVID

Ocular abnormalities have been reported in association with viral infections, including Long COVID, a debilitating illness caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). This report presents a case of a female patient diagnosed with Acute Macular Neuroretinopathy (AMN) following an Influenza A virus infection during Long COVID who experienced severe inflammation symptoms and ocular complications. We hypothesize that the rare occurrence of AMN in this patient could be associated with the immune storm secondary to the viral infection during Long COVID.

Response of Human Retinal Microvascular Endothelial Cells to Influenza A (H1N1) Infection and the Underlying Molecular Mechanism

Purpose

Whether H1N1 infection-associated ocular manifestations result from direct viral infections or systemic complications remains unclear. This study aimed to comprehensively elucidate the underlying causes and mechanism.

Method

TCID50 assays was performed at 24, 48, and 72 hours to verify the infection of H1N1 in human retinal microvascular endothelial cells (HRMECs). The changes in gene expression profiles of HRMECs at 24, 48, and 72 hours were characterized using RNA sequencing technology. Differentially expressed genes (DEGs) were validated using real-time quantitative polymerase chain reaction and Western blotting. CCK-8 assay and scratch assay were performed to evaluate whether there was a potential improvement of proliferation and migration in H1N1-infected cells after oseltamivir intervention.

Results

H1N1 can infect and replicate within HRMECs, leading to cell rounding and detachment. After H1N1 infection of HRMECs, 2562 DEGs were identified, including 1748 upregulated ones and 814 downregulated ones. These DEGs primarily involved in processes such as inflammation and immune response, cytokine-cytokine receptor interaction, signal transduction regulation, and cell adhesion. The elevated expression levels of CXCL10, CXCL11, CCL5, TLR3, C3, IFNB1, IFNG, STAT1, HLA, and TNFSF10 after H1N1 infection were reduced by oseltamivir intervention, reaching levels comparable to those in the uninfected group. The impaired cell proliferation and migration after H1N1 infection was improved by oseltamivir intervention.

Conclusions

This study confirmed that H1N1 can infect HRMECs, leading to the upregulation of chemokines, which may cause inflammation and destruction of the blood-retina barrier. Moreover, early oseltamivir administration may reduce retinal inflammation and hemorrhage in patients infected with H1N1.

Differentiation between acute macular neuroretinopathy and paracentral acute middle maculopathy in elderly persons: two case reports

Background

We report one case of rare acute macular neuroretinopathy (AMN) in an elderly patient with hypertension and one case of common paracentral acute middle maculopathy (PAMM) in a patient with diabetes mellitus to illustrate the difference between the two diseases.

Case presentation

This report describes two cases, one involving AMN and the other PAMM. The first patient was a 70-year-old man complaining of blurred vision for 3 days. He was examined with fundus photography, optical coherence tomography angiography (OCTA) and optical coherence tomography (OCT); a diagnosis of AMN was established. The second patient was a 50-year-old woman who complained of decreased vision during the past month. She had had diabetes mellitus for 6 years. From the ophthalmic imaging examination, the patient was diagnosed with PAMM and non-proliferative diabetic retinopathy (NPDR). Both patients were treated with drugs for improving microcirculation and neurotrophic drugs; however, there was no significant improvement in visual acuity.

Conclusions

AMN is more common in young patients and is rarely observed in elderly patients with systemic diseases. The OCTA examination has an auxiliary diagnostic value for deep retinal capillary network ischaemia. Meanwhile, OCT examination has important imaging value in differentiating AMN from PAMM and can help avoid missed diagnoses.

Non-invasive brain microcurrent stimulation therapy of long-COVID-19 reduces vascular dysregulation and improves visual and cognitive impairment

BACKGROUND

An effective treatment is needed for long-COVID patients which suffer from symptoms of vision and/or cognition impairment such as impaired attention, memory, language comprehension, or fatigue.

OBJECTIVE

Because COVID-19infection causes reduced blood flow which may cause neuronal inactivation, we explored if neuromodulation with non-invasive brain stimulation using microcurrent (NIBS), known to enhance blood flow and neuronal synchronization, can reduce these symptoms.

METHODS

Two female long-COVID patients were treated for 10-13 days with alternating current stimulation of the eyes and brain. While one patient (age 40) was infected with the SARS CoV-2 virus, the other (age 72) developed symptoms following AstraZeneca vaccination. Before and after therapy, cognition was assessed subjectively by interview and visual fields quantified using perimetry. One patient was also tested with a cognitive test battery and with a retinal dynamic vascular analyser (DVA), a surrogate marker of vascular dysregulation in the brain.

RESULTS

In both patients NIBS markedly improved cognition and partially reversed visual field loss within 3-4 days. Cognitive tests in one patient confirmed recovery of up to 40-60% in cognitive subfunctions with perimetry results showing stable and visual field recovery even during follow-up. DVA showed that NIBS reduced vascular dysregulation by normalizing vessel dynamics (dilation/constriction), with particularly noticeable changes in the peripheral veins and arteries.

CONCLUSIONS

NIBS was effective in improving visual and cognitive deficits in two confirmed SARS-COV-2 patients. Because recovery of function was associated with restoration of vascular autoregulation, we propose that (i) hypometabolic, "silent" neurons are the likely biological cause of long-COVID associated visual and cognitive deficits, and (ii) reoxygenation of these "silent" neurons provides the basis for neural reactivation and neurological recovery. Controlled trials are now needed to confirm these observations.

Temporary Central Vision Blindness After Oseltamivir Administration in a 15-Year-Old Pediatric Male Positive for Influenza A

Objective: A 15-year-old pediatric male patient was influenza A positive and started on oseltamivir at an outpatient clinic. Method: The next morning the patient presented to the emergency department (ED) with a chief complaint of visual disturbances including decreased central vision. Prior to presenting to the ED the patient was evaluated by his optometrist and his eye exam tested 20/400 bilaterally. His previous year's eye exam was normal, 20/25 bilaterally. Results: In the ED, the patient had an MRI which showed a normal appearing optic nerve, chiasm, and optic tracts. The oseltamivir therapy was discontinued, and the patient followed up with an ophthalmologist outpatient. Conclusion: At a 10-week follow-up visit the patient had 90% recovery of his vision.

Did the COVID-19 Pandemic Increase the Incidence of Acute Macular Neuroretinopathy?

Background: Acute macular neuroretinopathy (AMN) is an increasingly diagnosed disorder associated with several diseases. The aim of this study was to report the incidence of AMN cases diagnosed during the 2020 coronavirus disease 2019 (COVID-19) pandemic year in a French hospital, and to describe their different forms. Methods: All patients diagnosed between 2019 and 2020, in Paris Rothschild Foundation Hospital, with AMN, paracentral acute middle maculopathy (PAMM) and multiple evanescent white dot syndrome (MEWDS) were retrospectively collected using the software Ophtalmoquery^® (Corilus, V1.86.0018, 9050 Gand, Belgium). Systemic and ophthalmological data from AMN patients were analyzed. Results: Eleven patients were diagnosed with AMN in 2020 vs. only one patient reported in 2019. The incidence of AMN significantly increased from 0.66/100,000 visits in 2019 to 8.97/100,000 visits in 2020 (p = 0.001), whereas the incidence of PAMM and MEWDS remained unchanged. Four (36%) of these AMN patients were tested for COVID-19 and received positive polymerase chain reaction (PCR) tests. Conclusions: The incidence of AMN cases increased significantly in our institution in 2020, which was the year of the COVID-19 pandemic. All AMN-tested patients received a positive COVID PCR test, suggesting a possible causative link. According to the different clinical presentations, AMN may reflect different severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pathogenic mechanisms.

Acute macular neuroretinopathy as a manifestation of coronavirus disease 2019: A case report

The current findings is important in raising clinicians' awareness of the possibility of coincident acute macular neuroretinopathy (AMN) and COVID-19 as a potential cause of retinal vascular damage and ischemia.

No findings of SARS-CoV-2 in conjunctival swabs from patients at an emergency outpatient ophthalmological healthcare facility in a Swedish county hospital: a cross-sectional study

Background

COVID-19 is caused by SARS-CoV-2. Virus has been found in conjunctiva of hospitalised patients with COVID-19. Conjunctivitis has also been reported as a presenting symptom of disease.

Objective

The aims of the study were to investigate the prevalence of SARS-CoV-2 in the conjunctiva and throat among patients presenting at the emergency outpatient ophthalmological healthcare facility at a county hospital along with investigating the seroprevalence of SARS-CoV-2 among staff at the department.

Methods and Analysis

Swabs from conjunctiva and throat of patients were analysed with real-time reverse transcriptase PCR (RT-PCR) for SARS-CoV-2. Blood samples for serological analysis were obtained from staff. A questionnaire was used to investigate symptoms associated with COVID-19 during the last 3 months as well as symptoms for which the patients were seeking ophthalmological healthcare.

Results

In total, 68 patients and 70 individuals from the staff were included in the study. Conjunctivitis was observed in 7% of patients. One patient, presenting with reduced visual acuity due to preretinal haemorrhage in the macula, was positive for SARS-CoV-2 in throat swab. Contact tracing was negative. All other RT-PCR tests were negative. Seropositivity for SARS-CoV-2 was found in 4% of staff.

Conclusions

Our study demonstrated low prevalence of SARS-CoV-2 among patients as well as low seroprevalence of SARS-CoV-2 IgG-antibodies among staff at the ophthalmological ward. The risk for contracting COVID-19 at the department was small. Follow-up investigation is planned.

Acute macular neuroretinopathy in a patient with acute myeloid leukemia and deceased by COVID-19: a case report

PURPOSE

Acute macular neuroretinopathy (AMN) is a visual-deteriorating rare clinical entity with an uncertain etiology. We aimed to report a case of AMN and underlying disease of acute myeloid leukemia (AML).

CASE PRESENTATION

A thirty-five-year-old female patient with bone marrow biopsy confirmed AML, and bicytopenia, under chemotherapy, complained of sudden paracentral visual field defect in her right eye was referred. Visual acuity was 20/20 in both eyes. Posterior segment evaluation revealed multiple Roth's spots. Optical coherence tomography (OCT) demonstrated hyper-reflectivity band, in the outer nuclear layer and outer plexiform layer, nasal to the fovea of the right eye, and hyperreflective patch in outer retina segmentation en-face OCT, suggestive of the diagnosis of AMN. Nine days after AMN diagnosis, dyspnea, malaise, and cough was initiated. Ground glass opacities in lung CT scan, beside reverse transcription polymerase chain reaction of severe acute respiratory syndrome coronavirus-2, was conclusive of coronavirus disease 2019 (COVID-19). The patient deceased after 6 days.

CONCLUSION

We report a rare case of AMN following AML. Our findings support the role of ischemia in the outer retina, of which AML may contributed to the pathophysiological process. The patient has deceased less than 2 weeks from AMN initiation.

Bilateral optic neuritis with spine demyelination associated with influenza A H1N1 infection

Purpose

To report a rare case of optic neuritis with spine demyelination following H1N1 virus infection.

Observation

A 66-year-old female presented with decreased vision in both eyes (left > right) following a recent episode of fever and flu. She was diagnosed as H1N1 infection confirmed by viral antigen analysis of throat swab. On examination, she had a profound vision drop in the left eye with optic disc edema. MRI brain and orbit revealed bilateral optic nerve and frontal dural thickening with a ring-enhancing lesion in the right frontal lobe. MRI spine showed long cord signals at T1-T7 suggestive of demyelination. The patient had a complete recovery of vision and visual fields after intravenous and oral steroids.

Conclusion/Importance

Influenza A virus can manifest with a wide range of symptoms including flu-like illness to neurological complications. This case highlights optic neuritis as a presenting feature of H1N1 infection.

Bilateral Acute Macular Neuroretinopathy in a Young Patient: Imaging and Visual Field during Two-Year-Follow-Up

Acute macular neuroretinopathy (AMN) is a rare disorder. We report a case of bilateral AMN in a young female patient, without any risk factors. She referred a positive scotoma in both eyes after flu-like symptoms. Fundus examination revealed parafoveal dark-reddish oval lesions in both eyes. Therefore, we performed visual field, optical coherence tomography (OCT), fluorescein angiography (FA) and indocyanine green angiography (ICG) at baseline and several times during the two years of follow-up. The infrared (IR) imaging showed one rounded hyporeflective lesion in the left eye and two similar lesions in the right eye. The OCT demonstrated the characteristic alterations in the outer retina. The visual field also demonstrated scotomas corresponding with these lesions. The OCT and IR features disappeared at the end of the follow-up except for the left eye, which continued to have hyperreflective spots in the outer plexiform layer. The patient complained about a residual scotoma only in the left eye after two years. Our case shows a difference in disease progression in the two eyes of the same patient, suggesting that several mechanisms can be implicated in the pathology of AMN.